Member Handbook - Aetna...Helpful Information Address Aetna Better Health of Virginia 9881 Mayland Drive Richmond, VA 23233 Member Services 1-855-652-8249 Representatives available

AETNA BETTER HEALTH® OF VIRGINIACommonwealth Coordinated Care Plus (CCC Plus)

Member Handbook

www.aetnabetterhealth.com/virginia

VA-17-06-08

Helpful Information

AddressAetna Better Health of Virginia9881 Mayland DriveRichmond, VA 23233

Member Services1-855-652-8249

Representatives available 24 hours a day, 7 days a week

Services for the Hearing and Speech ImpairedTTY/TDD 711 or 1-800-828-1120

Language Translation and Interpreter Services1-855-652-8249

Includes member request for an interpreter at doctor appointments and translation of member documents in print and on our website. See inside of handbook for more details.

Behavioral Health and Substance Use Services and 24 Hour Helpline1-855-652-8249

Care Management1-855-652-8249

24 Hour Nurseline1-855-652-8249

Vision1-855-652-8249

Smiles for Children (Children under 21)1-888-912-3456

Adult Dental1-855-652-8249

Transportation1-855-652-8249

See inside of handbook for more details.

Grievance and AppealsAetna Better Health of VirginiaAttn: Appeals and Grievance Manager9881 Mayland DriveRichmond, VA 232331-855-652-8249

Report Fraud and Abuse1-844-317-5825

CCC Plus Helpline1-844-374-9159 (TTY 1-800-817-6608)cccplusva.com

Department of Medical Assistance Services (DMAS)www.dmas.virginia.gov

Department of Social Serviceswww.dss.virginia.gov

Reporting Abuse, Neglect, and ExploitationAdult Protective Services (APS)24 Hour Hotline1-888-832-3858

Personal Information

_______________________________________________________________________________My Member ID Number

_______________________________________________________________________________My Primary Care Provider (PCP)

_______________________________________________________________________________My PCP’s Phone Number

www.aetnabetterhealth.com/virginia

Aetna Better Health Member Services 1-855-652-8249 (TTY 711)24 hours a day/7 days a week. The call is free. 1

Aetna Better Health® of Virginia

Effective August 1, 2017

Commonwealth of VirginiaDepartment of Medical Assistance Services

Commonwealth Coordinated Care Plus ProgramMember Handbook

Aetna Better Health Member Services 1-855-652-8249 (TTY 711)24 hours a day/7 days a week. The call is free.2


Table of ContentsHelp in Other Languages or Alternate Formats ........................................................................................9

1. Commonwealth Coordinated Care Plus (CCC Plus) ...................................................................13Welcome to Aetna Better Health of Virginia .......................................................................................... 13How to Use This Handbook ...........................................................................................................................13Other Information We Will Send to You ...................................................................................................13

Aetna Better Health Member ID Card ....................................................................................................14Provider and Pharmacy Directory ............................................................................................................14

Important Phone Numbers ...........................................................................................................................15

2. What is Commonwealth Coordinated Care Plus ........................................................................17What Makes You Eligible to be a CCC Plus Member ............................................................................. 17

CCC Plus Enrollment ................................................................................................................................... 17Reasons You Would Not be Eligible to Participate in CCC Plus ........................................................ 17Coverage for Newborns Born to Moms Covered Under CCC Plus ................................................. 18Medicaid Eligibility ........................................................................................................................................18

Choosing or Changing Your Health Plan ...................................................................................................18Health Plan Assignment .............................................................................................................................18You Can Change Your Health Plan Through the CCC Plus Helpline ................................................ 19Automatic Re‑Enrollment ...........................................................................................................................19What is Aetna Better Health of Virginia’s Service Area ....................................................................... 20

If You Have Medicare and Medicaid .......................................................................................................... 21You Can Choose the Same Health Plan for Medicare and Medicaid .............................................. 22

How to Contact the Medicare State Health Insurance Assistance Program (SHIP) ................. 25

3. How CCC Plus Works ..............................................................................................................................25What are the Advantages of CCC Plus ....................................................................................................... 25What are the Advantages of Choosing Aetna Better Health ............................................................. 26

The care you need, when you need it ..................................................................................................... 26Local presence, national strength ........................................................................................................... 26Enhancing service, quality and accessibility with value‑added benefits ......................................... 27

Continuity of Care Period ............................................................................................................................... 28If You Have Other Coverage .......................................................................................................................... 29


4. Your Care Coordinator ...........................................................................................................................29How Your Care Coordinator Can Help ...................................................................................................... 29What is a Health Risk Assessment .............................................................................................................. 30What is a Care Plan ...........................................................................................................................................30How to Contact Your Care Coordinator ....................................................................................................31

5. Help From Member Services ...............................................................................................................31How to Contact Aetna Better Health Member Services ..................................................................... 31How Member Services Can Help .................................................................................................................. 32Medical Advice Line Available 24 Hours a Day, 7 Days a Week ........................................................ 32Behavioral Health Crisis Line Available 24 Hours a Day, 7 Days a Week ...................................... 33Addiction and Recovery Treatment Services (ARTS) Advice Line Available 24 Hours a Day, 7

Days a Week ........................................................................................................................................................33If You Do Not Speak English ..........................................................................................................................33

If You Have a Disability and Need Assistance in Understanding Information or Working with Your Care Coordinator ..........................................................................................................................33If You Have Questions About Your Medicaid Eligibility ....................................................................... 33

6. How to Get Care and Services ...........................................................................................................34How to Get Care from Your Primary Care Physician ............................................................................ 34

Your Primary Care Physician .....................................................................................................................34Choosing Your PCP ......................................................................................................................................34If You have Medicare, Tell us About Your PCP ...................................................................................... 35If Your Current PCP is not in Our Network ............................................................................................ 35Changing Your PCP ......................................................................................................................................35Getting an Appointment with Your PCP ................................................................................................. 36Appointment Standards ............................................................................................................................. 36

How to Get Care From Network Providers .............................................................................................. 36Travel Time and Distance Standards ...................................................................................................... 36Accessibility ....................................................................................................................................................37What are “Network Providers” .................................................................................................................. 37What are “Network Pharmacies” .............................................................................................................. 37What are Specialists ....................................................................................................................................38Utilization Management .............................................................................................................................38Utilization management affirmative statement about incentives .................................................... 39If Your Provider Leaves Our Plan ............................................................................................................. 40


How to Get Care from Out‑of‑Network Providers ................................................................................ 41Care From Out‑of‑State Providers ........................................................................................................... 42Network Providers Cannot Bill You Directly .......................................................................................... 42If You Receive a Bill for Covered Services .............................................................................................. 42

If You Receive Care From Providers Outside of the United States ................................................. 42

7. How to Get Care for Emergencies .....................................................................................................43What is an Emergency .....................................................................................................................................43What to do in an Emergency .........................................................................................................................43What is a Medical Emergency .......................................................................................................................43What is a Behavioral Health Emergency ...................................................................................................43Examples of Non‑Emergencies .....................................................................................................................43If You Have an Emergency When Away From Home ............................................................................ 44What is Covered if You Have an Emergency ............................................................................................ 44Notifying Aetna Better Health About Your Emergency....................................................................... 44After an Emergency ..........................................................................................................................................44If You Are Hospitalized ....................................................................................................................................44If it Wasn’t a Medical Emergency .................................................................................................................45

8. How to Get Urgently Needed Care ...................................................................................................45What is Urgently Needed Care .....................................................................................................................45

9. How to Get Your Prescription Drugs ...............................................................................................45Rules for Aetna Better Health’s Outpatient Drug Coverage ............................................................. 45Getting Your Prescriptions Filled ................................................................................................................. 46List of Covered Drugs .......................................................................................................................................46Limits for Coverage of Some Drugs ............................................................................................................ 47

Getting Approval in Advance ..................................................................................................................... 47Trying a Different Drug First ......................................................................................................................48Quantity Limits ..............................................................................................................................................48Emergency Supply .......................................................................................................................................48

Non Covered Drugs ...........................................................................................................................................48Changing Pharmacies ......................................................................................................................................49What if You Need a Specialized Pharmacy .............................................................................................. 49Can You Use Mail‑Order Services to Get Your Drugs ........................................................................... 49Can You Get a Long‑Term Supply of Drugs .............................................................................................. 49


Can You Use a Pharmacy that is Not in Aetna Better Health’s Network...................................... 50What is the Patient Utilization Management and Safety (PUMS) Program ................................. 51

10. How to Access Your CCC Plus Benefits .........................................................................................52CCC Plus Benefits ..............................................................................................................................................52General Coverage Rules .................................................................................................................................. 52Benefits Covered Through Aetna Better Health .................................................................................... 53Extra Benefits We Provide That are not Covered by Medicaid ........................................................ 56How to Access Early and Periodic Screening, Diagnostic, and Treatment Services ................. 57

What is EPSDT ...............................................................................................................................................57Getting EPSDT Services .............................................................................................................................. 57Getting Early Intervention Services ..........................................................................................................58

How to Access Behavioral Health Services .............................................................................................. 59How to Access Addiction and Recovery Treatment Services (ARTS) .............................................. 60How to Access Long‑Term Services and Supports (LTSS) ................................................................... 61

Commonwealth Coordinated Care Plus Waiver ................................................................................... 61How to Self‑Direct Your Care .................................................................................................................... 62Nursing Facility Services ............................................................................................................................. 62Screening for Long‑term Services and Supports ................................................................................ 63Freedom of Choice ...................................................................................................................................... 63

How to Get Services if You are in a Developmental Disability Waiver .......................................... 63How to Get Non‑Emergency Transportation Services ......................................................................... 64

Non‑Emergency Transportation Services Covered by Aetna Better Health ................................. 64Transportation to and From DD Waiver Services ................................................................................ 65

11. Services Covered Through the DMAS ...........................................................................................66

Medicaid Fee‑For‑Service Program .......................................................................................................66Carved‑Out Services .........................................................................................................................................66Services That Will End Your CCC Plus Enrollment ................................................................................. 67

12. Services Not Covered by CCC Plus ..................................................................................................68If You Receive Non‑Covered Services ......................................................................................................... 69

13. Member Cost Sharing ..........................................................................................................................69Member Patient Pay Towards Long‑term Services and Supports .................................................. 70Medicare Members and Part D Drugs ....................................................................................................... 70


14. Service Authorization and Benefit Determination .................................................................70Service Authorization .......................................................................................................................................70Service Authorizations and Continuity of Care ...................................................................................... 71How to Submit a Service Authorization Request ................................................................................ 71What Happens After We Get Your Service Authorization Request ................................................. 72Timeframes for Service Authorization Review ....................................................................................... 73

Benefit Determination ................................................................................................................................ 75Advance Notice .............................................................................................................................................75Post Payment Review .................................................................................................................................. 75

15. Appeals, State Fair Hearings, and Complaints (Grievances) ..............................................75Your Right to Appeal.........................................................................................................................................75

Authorized Representative ........................................................................................................................ 76Adverse Benefit Determination ................................................................................................................ 76How to Submit Your Appeal ...................................................................................................................... 76Continuation of Benefits ............................................................................................................................ 77What Happens After We Get Your Appeal ............................................................................................. 77Timeframes for Appeals ............................................................................................................................. 77Written Notice of Appeal Decision ........................................................................................................... 78

Your Right to a State Fair Hearing ............................................................................................................... 79Standard or Expedited Review Requests ............................................................................................... 79Authorized Representative ........................................................................................................................ 79Where to Send the State Fair Hearing Request ................................................................................... 79After You File Your State Fair Hearing Appeal....................................................................................... 80State Fair Hearing Timeframes ............................................................................................................... 80Continuation of Benefits ............................................................................................................................ 80If the State Fair Hearing Reverses the Denial ....................................................................................... 80If You Disagree with the State Fair Hearing Decision .......................................................................... 81

Your Right to File a Complaint (Grievance) .............................................................................................. 81Timeframe for Complaints .........................................................................................................................81What Kinds of Problems Should be Complaints .................................................................................. 81There Are Different Types of Complaints ............................................................................................... 82Internal Complaints ..................................................................................................................................... 82External Complaints ....................................................................................................................................83


16. Member Rights .......................................................................................................................................84Your Rights ...........................................................................................................................................................84Your Right to be Safe ........................................................................................................................................86Your Right to Confidentiality ........................................................................................................................ 86Your Right to Privacy .......................................................................................................................................86How to Join the Member Advisory Committee ...................................................................................... 87

17. Member Responsibilities ....................................................................................................................90Your Responsibilities ........................................................................................................................................90Advance Directives ............................................................................................................................................91

Where to Get the Advance Directives Form .......................................................................................... 91Completing the Advance Directives Form.............................................................................................. 91Share the Information with People You Want to Know About It ...................................................... 91We Can Help You Get or Understand Advance Directives Documents ......................................... 92Other Resources ..........................................................................................................................................92If Your Advance Directives Are Not Followed ........................................................................................ 92

18. Fraud, Waste, and Abuse ....................................................................................................................93What is Fraud, Waste, and Abuse ................................................................................................................93How Do I Report Fraud, Waste, or Abuse .................................................................................................94

19. Other Important Resources ..............................................................................................................95

20. Important Words and Definitions Used in this Handbook ..................................................96Aetna Better Health Member Services ....................................................................................................102


Help in Other Languages or Alternate FormatsThis handbook is available for free in other languages and formats including on‑line, in large print, Braille or Audio CD. To request the handbook in an alternate format and or language, please contact our Member Services staff at 1‑855‑652‑8249.

If you have any problems reading or understanding this information, please contact our Member Services staff at 1‑855‑652‑8249 (TTY 1‑800‑828‑1120) for help at no cost to you.

We provide reasonable accommodations and communications access to persons with disabilities. Individuals who are deaf or hard of hearing or who are speech‑impaired, who want to speak to a Member Services representative, and who have a TTY or other assistive device can dial 711 to reach a relay operator. They will help you reach our Member Services staff. If you cannot reach us at this number, you may contact us through Virginia Relay toll‑free at TDD 1‑800‑828‑1120 or Voice 1‑800‑828‑1140.


Nondiscrimination Notice

Aetna complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Aetna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Aetna:• Provides free aids and services to people with disabilities to communicate effectively

with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats,

other formats)• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreterso Information written in other languages

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card or 1-800-385-4104. (TTY: 711)

If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights Coordinator at:

Address: Attn: Civil Rights Coordinator 4500 East Cotton Center BoulevardPhoenix, AZ 85040

Telephone: 1-888-234-7358 (TTY 711)Email: [email protected]

You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, and its affiliates.


Multi-language Interpreter Services

ENGLISH: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on the back of your ID card or 1-800-385-4104 (TTY: 711).

SPANISH: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en el reverso de su tarjeta de identificación o al 1-800-385-4104 (TTY: 711).

KOREAN: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드 뒷면에 있는 번호로나 1-800-385-4104 (TTY: 711) 번으로 연락해 주십시오.

VIETNAMESE: CHÚ Ý: nếu bạn nói tiếng việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Hãy gọi số có ở mặt sau thẻ id của bạn hoặc 1-800-385-4104 (TTY: 711).

CHINESE: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電您的 ID 卡背面的電話號碼或 1-800-385-4104 (TTY: 711)。

ARABIC:

TAGALOG: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tumawag sa numero na nasa likod ng iyong ID card o sa 1-800-385-4104 (TTY: 711).PERSIAN:

AMHARIC: ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ ያለ ምንም ክፍያ የቋንቋ ድጋፍ አገልግሎቶችን ማግኘት ይችላሉ። በእርስዎ አይዲ ካርድ ጀርባ ወዳለው ስልክ ቁጥር ወይም በስልክ ቁጥር 1-800-385-4104 (TTY: 711) ይደውሉ።.

URDU:

FRENCH: ATTENTION: si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le numéro indiqué au verso de votre carte d’identité ou le 1-800-385-4104 (ATS : 711).

RUSSIAN: ВНИМАНИЕ: если вы говорите на русском языке, вам могут предоставить бесплатные услуги перевода. Позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки, или по номеру 1-800-385-4104 (TTY: 711).

HINDI: ध्यान दें: ्दद आप हिदंी भयाषया बोलते िैं तो आपके ललए भयाषया सिया्तया सेवयाएं लन: शुलक उपलब्ध िैं। अपने आईडी कयाड्ड के पृष्ठ भयाग में ददए गए नमबर अथवया 1-800- 385-4104 (TTY: 711) पर कॉल करें।GERMAN: ACHTUNG: Wenn Sie deutschen sprechen, können Sie unseren kostenlosen Sprachservice nutzen. Rufen Sie die Nummer auf der Rückseite Ihrer ID-Karte oder 1-800-385-4104 (TTY: 711) an.

BENGALI: লক্ষ্য কর‍ুনঃ যদি আপদন বাংলায় কথা বললন, তাহলল দনঃ খরচায় ভাষা সহায়তা পদরলষবা উপলব্ধ আলে। আপনার পদরচয়পলরের উল্াদিলক থাকা নম্বলর অথবা 1-800- 385-4104 (TTY: 711) নম্বলর ফ�ান কর‍ুন।

IGBO (IBO): NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ nọmba dị n’azụ nke kaadị ID gị ma ọ bụ 1-800-385-4104 (TTY: 711).

YORUBA: ÀKÍYÈSÍ: Tí o bá sọ èdè Yorùbá, àwọn olùrànlọ́wọ́ ìpèsè èdè ti wá ní lẹ̀ fún ọ lọ́fẹ̀ẹ́, pe nọ́ńbà tí ó wà lẹ́yìn káàdì ìdánimọ̀ rẹ tàbí 1-800-385-4104 (TTY: 711).

VA-16-09-02

ملحوظة: إذا كنت تتحدث باللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل على الرقم الموجود خلف بطاقتك الشخصية أو عل 4104-385-800-1 )للصم والبكم: 711(.

ARABIC:

اگر به زبان فارسی صحبت می کنيد، به صورت رايگان می توانيد به خدمات کمک زبانی دسترسی داشته باشيد. با شماره درج شده در پشت کارت شناسايی يا با شماره TTY: 711( 1-800-385-4104( تماس بگيريد.

PERSIAN:

توجہ دیں: اگر آپ اردو زبان بولتے ہیں، تو زبان سے متعلق مدد کی خدمات آپ کے لئے مفت دستیابہیں ۔ اپنے شناختی کارڈ کے پیچھے موجود نمبر پر یا TTY: 711( 1-800-385-4104( پر رابطہ کریں۔

URDU:

KRU: TÛ DƐ NÂ JIE̍̍ BÒ: ɛ yemâ wlu bɛɛ̀ ̀ n̂ a po Klào Win, nee̍̍ â-a̍ win kwa cɛti y̍ɔ+ ne-la,̍ i bɛle-̍o̍ bi ma-̍o̍ mû bò ko̍ putu bò. Da ̍nɔbâ ne ̍ɛ ̂nea-o̍ n̂-a ̍ji̍ e ̍jipolê kateh̍ jɛ na ̍kpo̍h, mɔɔ̀ ̍1-800-385-4104 )TTY: 711).

1-800-385-4104

1-800-385-4104



1. Commonwealth Coordinated Care Plus (CCC Plus)

Welcome to Aetna Better Health of Virginia Thank you for being a Member of Aetna Better Health, a Commonwealth Coordinated Care Plus (CCC Plus) plan. If you are a new Member, we will get in touch with you in the next few weeks to go over some very important information with you. You can ask us any questions you have, or get help making appointments. If you need to speak with us right away or before we contact you, call us at the number listed below.

On behalf of all of those associated with Aetna Better Health, we welcome you. We have built a strong network of area physicians, hospitals and other health care providers to offer a broad range of services for your medical needs.

At Aetna Better Health, we believe in delivering the best care through a collaborative approach. We start by recognizing that our providers’ knowledge and expertise is essential for improving the effectiveness and efficiency of our programs and services. We also believe that our members should have the opportunity to be leaders in their care. We work with you, your providers, and caregivers to achieve your goals.

Please take some time to read these materials to learn more about your Aetna Better Health coverage. Our Member Services Department is here to answer any questions you may have about your coverage and services. You can reach us at 1‑855‑652‑8249, 24 hours a day/7 days a week. We look forward to serving you and your family.

How to Use This HandbookThis handbook will help you understand your Commonwealth Coordinated Care Plus (CCC Plus) benefits and how you can get help from Aetna Better Health. This handbook is your guide to health services. It explains your health care, behavioral health, prescription drug, and long‑term services and supports coverage under the CCC Plus program. It tells you the steps you can take to make your health plan work for you.

Feel free to share this handbook with a family member or someone who knows your health care needs. When you have a question, check this handbook, call our Member Services unit, call your Care Coordinator, or visit our website at www.aetnabetterhealth.com/virginia.

Other Information We Will Send to YouYou should have already received your Aetna Better Health Member ID Card, and information on how to access a Provider and Pharmacy Directory, and a List of Covered Drugs. You can also search for a provider or pharmacy location by using the online network tool on the Aetna Better Health of Virginia website. www.aetnabetterhealth.com/virginia.


Aetna Better Health Member ID Card

Show your Aetna Better Health ID card when you receive Medicaid services, including when you get long‑term services and supports, at doctor visits, and when you pick up prescriptions. You must show this card when you get any services or prescriptions. If you have Medicare and Medicaid, show your Medicare and Aetna Better Health of Virginia ID card when you receive services. Below is a sample card to show you what yours will look like:

Non‑Dual members

Dual members

If you haven’t received your card, or if your card is damaged, lost, or stolen, call Member Services at the number at the bottom of the page right away, and we will send you a new card.

In addition to your Aetna Better Health card, keep your Commonwealth of Virginia Medicaid ID card to access services that are covered by the State, under the Medicaid fee‑for‑service program. These services are described in Services Covered through Medicaid Fee‑For‑Service, in Section 11 of this handbook.

Provider and Pharmacy DirectoryYou can ask for a paper copy of the Provider and Pharmacy Directory by calling Member Services at the number at the bottom of the page. The most updated


versions of the directories are located on our website. The Provider and Pharmacy Directory provides information on health care professionals (such as doctors, nurse practitioners, psychologists, etc.), facilities (hospitals, clinics, nursing facilities, etc.), support providers (such as adult day health, home health providers, etc.), and pharmacies in the Aetna Better Health network. While you are a Member of our plan, you generally must use one of our network providers and pharmacies to get covered services. There are some exceptions, however, including: • When you first join our plan (see Continuity of Care Period in Section 3 of this

handbook), • If you have Medicare (see How to Get Care From Your Primary Care Physician in

Section 6 of this handbook, and• In several other circumstances (see How to Get Care From Out‑of‑Network Providers

in Section 6 of this handbook.)

You can ask for a paper copy of the Provider and Pharmacy Directory or List of Covered Drugs by calling Member Services at the number at the bottom of the page. You can also see the Provider and Pharmacy Directory and List of Covered Drugs at www.aetnabetterhealth.com/virginia or download it from this website. Refer to List of Covered Drugs in Section 9 of this handbook.

The Provider & Pharmacy Directory gives you information on how to obtain care and lists health care professionals (such as doctors, nurse practitioners, and psychologists), facilities (such as hospitals or clinics), and support providers (such as Adult Day Health and Home Health providers) that you may see as an Aetna Better Health of Virginia member. It also lists the pharmacies that you may use to get your prescription drugs. The online listing has the most up‑to‑date information.

Important Phone NumbersYour Care Coordinator 1‑855‑652‑8249Aetna Better Health Member Services 1‑855‑652‑8249Aetna Better Health24/7 Medical /Behavioral Health Advice Line

1‑855‑652‑8249

Aetna Better Health24/7 Behavioral Health Crisis Line

1‑855‑652‑8249

Magellan of Virginia; DMAS Behavioral Health Services Administrator

Toll‑free:1‑800‑424‑4046

TDD: 1‑800‑424‑4048

Or dial 711 to reach a relay operator

http://www.magellanofvirginia.com/


Important Phone NumbersCCC Plus Helpline 1‑844‑374‑9159

TDD: 1‑800‑817‑6608

or visit the website at cccplusva.com.Department of Health and Human Services’ Office for Civil Rights

1‑800‑368‑1019 or visit the website at www.hhs.gov/ocr

Aetna Better Health Adult Dental 1‑844‑824‑2018Smiles for Children through DentaQuest, DMAS Dental Benefits Administrator

For questions or to find a dentist in your area, call Smiles For Children at 1‑888‑912‑3456. Information is also available on the DMAS website at: http://www.dmas.virginia.gov/Content_pgs/dnt‑home.aspx

or the DentaQuest website at: http://www.dentaquestgov.com/

Aetna Better Health of Virginia Transportation 1‑855‑652‑8249DMAS Transportation Contractor for transportation to and from DD Waiver Services

1‑866‑386‑8331

TTY 1‑866‑288‑3133

Or dial 711 to reach a relay operatorOffice of the State Long‑Term Care Ombudsman

1‑800‑552‑5019

TTY 1‑800‑464‑9950


2. What is Commonwealth Coordinated Care Plus

The Commonwealth Coordinated Care Plus (CCC Plus) program is a Medicaid managed care program through the Department of Medical Assistance Services (DMAS). Aetna Better Health was approved by DMAS to provide care coordination and health care services. Our goal is to help you improve your quality of care and quality of life.

What Makes You Eligible to be a CCC Plus MemberYou are eligible for CCC Plus when you have full Medicaid benefits, and meet one of the following categories:• You are age 65 and older,• You are an adult or child with a disability,• You reside in a nursing facility (NF),• You receive services through the CCC Plus home and community based services

waiver [formerly referred to as the Technology Assisted and Elderly or Disabled with Consumer Direction (EDCD) Waivers],

• You receive services through any of the three waivers serving people with developmental disabilities (Building Independence, Family & Individual Supports, and Community Living Waivers), also known as the DD Waivers.

CCC Plus EnrollmentEligible individuals must enroll in the CCC Plus program. DMAS and the CCC Plus Helpline manage the enrollment for the CCC Plus program. To participate in CCC Plus, you must be eligible for Medicaid.

Reasons You Would Not be Eligible to Participate in CCC PlusYou would not be able to participate in CCC Plus if any of the following apply: • You lose/lost Medicaid eligibility.• You do not meet one of the eligible categories listed above.• You are enrolled in hospice under the regular fee‑for‑service Medicaid program

prior to any CCC Plus benefit assignment. • You enroll in the Medicaid Health Insurance Premium Payment (HIPP) program.• You enroll in PACE (Program of All‑Inclusive Care for the Elderly). For more

information about PACE, talk to your Care Coordinator or visit: http://www.dmas.virginia.gov/Content_pgs/ltc‑pace.aspx.

• You enroll in the Medicaid Money Follows the Person (MFP) Program. For more information about MFP, talk to your Care Coordinator or visit: http://www.dmas.virginia.gov/Content_pgs/ltc‑mfp.aspx.


• You enroll in the Alzheimer’s Assisted Living Waiver. For more information about the Alzheimer’s Waiver, talk to your Care Coordinator or visit: http://www.dmas.virginia.gov/Content_pgs/ltc‑wvr_aal.aspx.

• You reside in an Intermediate Care Facility for Individuals with Intellectual and Developmental Disabilities (ICF/IID).

• You are receiving care in a Psychiatric Residential Treatment Level C Facility (children under age 21).

• You reside in a Veteran’s Nursing Facility.• You reside in one of these State long‑term care facilities: Piedmont, Catawba, Hiram

Davis, or Hancock.

Coverage for Newborns Born to Moms Covered Under CCC PlusIf you have a baby, you will need to report the birth of your child as quickly as possible to enroll your baby in Medicaid. You can do this by: • Calling the Cover Virginia Call Center at 1 (855) 242‑8282 to report the birth of your

child over the phone, or • Contacting your local Department of Social Services to report the birth of your child

You will be asked to provide your information and your baby’s: • Name• Date of Birth• Race• Gender• The baby’s mother’s name and Medicaid ID number

When first enrolled in Medicaid, your baby will be able to access health care through the Medicaid fee‑for‑service program. This means that you can take your baby to any provider in the Medicaid fee‑for‑service network for covered services. Look for additional information in the mail about how your baby will receive Medicaid coverage from DMAS.

Medicaid EligibilityMedicaid eligibility is determined by your local Department of Social Services (DSS). Contact your local DSS eligibility worker about any Medicaid eligibility questions. For more information, you can visit Cover Virginia at www.coverva.org, or call 1‑855‑242‑8282 or TDD: 1‑888‑221‑1590. The call is free.

Choosing or Changing Your Health PlanHealth Plan AssignmentYou received a notice from DMAS that included your initial health plan assignment. With that notice, DMAS included a comparison chart of health plans in your area. The assignment notice provided you with instructions on how to make your health plan selection.


You may have chosen us to be your health plan. If not, DMAS may have assigned you to our health plan based upon your history with us as your managed care plan. For example, you may have been enrolled with us before either through Medicare or Medicaid. You may also have been assigned to us if certain providers you see are in our network. These include nursing facilities, adult day health care, and private duty nursing providers.

You Can Change Your Health Plan Through the CCC Plus HelplineThe CCC Plus Helpline can help you choose the health plan that is best for you. For assistance, call the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608, or visit the website at cccplusva.com. The CCC Plus Helpline is available Monday through Friday (except on State Holidays) from 8:30 am to 6:00 pm. The CCC Plus Helpline can help you understand your health plan choices and answer your questions about which doctors and other providers participate with each health plan. The CCC Plus Helpline services are free and are not connected to any CCC Plus health plan.

You can change your health plan during the first 90 days of your CCC Plus program enrollment for any reason. You can also change your health plan once a year during open enrollment for any reason. Open enrollment occurs each year between October and December with a January 1st coverage begin date. You will get a letter from DMAS during open enrollment with more information. You may also ask to change your health plan at any time for “good cause,” which can include:• You move out of the health plan’s service area,• You need multiple services provided at the same time but cannot access them within

the health plan’s network,• Your residency or employment would be disrupted as a result of your residential,

institutional, or employment supports provider changing from an in‑network to an out‑of‑network provider, and

• Other reasons determined by DMAS, including poor quality of care and lack of access to appropriate providers, services, and supports, including specialty care.

The CCC Plus Helpline handles “good cause” requests and can answer any questions you may have. Contact the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608, or visit the website at cccplusva.com.

Automatic Re‑EnrollmentIf your enrollment ends with ABHVA and you regain eligibility for the CCC Plus program within 60 days or less, you will automatically be reenrolled with Aetna Better Health. You will also be sent a re‑enrollment letter from DMAS.


What is Aetna Better Health of Virginia’s Service AreaAetna Better Health’s service area includes the entire Commonwealth of Virginia—all 95 counties and 38 independent cities.

CountiesAccomackAlbemarleAlleghanyAmeliaAmherstAppomattoxArlingtonAugustaBathBedfordBlandBotetourtBrunswickBuchananBuckinghamCampbellCarolineCarrollCharles CityCharlotteChesterfieldClarkeCraigCulpeper

CumberlandDickensonDinwiddieEssexFairfaxFauquierFloydFluvannaFranklinFrederickGilesGloucesterGoochlandGraysonGreeneGreensvilleHalifaxHanoverHenricoHenryHighlandIsle of WightJames CityKing and QueenKing George

King WilliamLancasterLeeLoudounLouisaLunenburgMadisonMathewsMecklenburgMiddlesexMontgomeryNelsonNew KentNorthamptonNorthumberlandNottowayOrangePagePatrickPittsylvaniaPowhatanPrince EdwardPrince GeorgePrince WilliamPulaski

RappahannockRichmondRoanokeRockbridgeRockinghamRussellScottShenandoahSmythSouthamptonSpotsylvaniaStaffordSurrySussexTazewellWarrenWashingtonWestmorelandWiseWytheYork


CitiesAlexandriaBristolBuena VistaCharlottesvilleChesapeakeColonial HeightsCovingtonDanvilleEmporiaFairfax

Falls ChurchFranklinFredericksburgGalaxHamptonHarrisonburgHopewellLexingtonLynchburgManassas

Manassas ParkMartinsvilleNewport NewsNorfolkNortonPetersburgPoquosonPortsmouthRadfordRichmond

RoanokeSalemStauntonSuffolkVirginia BeachWaynesboroWilliamsburgWinchester

Only people who live in our service area can enroll with Aetna Better Health. If you move outside of our service area, you cannot stay in this plan. If this happens, you will receive a letter from DMAS asking you to choose a new plan. You can also call the CCC Plus Helpline if you have any questions about your health plan enrollment. Contact the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608 or visit the website at cccplusva.com.

If You Have Medicare and Medicaid If you have Medicare and Medicaid, some of your services will be covered by your Medicare plan and some will be covered by Aetna Better Health. We are your CCC Plus Medicaid Plan.

Types of Services UnderMedicare

Types of Services UnderCCC Plus (Medicaid)

• Inpatient Hospital Care (Medical and Psychiatric)

• Outpatient Care (Medical and Psychiatric)

• Physician and Specialists Services• X‑Ray, Lab Work and Diagnostic

Tests• Skilled Nursing Facility Care• Home Health Care• Hospice Care• Prescription Drugs• Durable Medical Equipment• For more information, contact

your Medicare Plan, visit Medicare.gov, or call Medicare at 1‑800‑633‑4227.

• Medicare Copayments • Hospital and Skilled Nursing when Medicare

Benefits are Exhausted• Long‑term nursing facility care (custodial)• Home and Community Based Waiver

Services like personal care and respite care, environmental modifications, and assistive technology services

• Community Behavioral Health Services• Medicare non‑covered services, like some

over the counter medicines, medical equipment and supplies, and incontinence products.


You Can Choose the Same Health Plan for Medicare and Medicaid

You have the option to choose the same health plan for your Medicare and CCC Plus Medicaid coverage. The Medicare plan is referred to as a Dual Special Needs Plan (D‑SNP). Having the same health plan for Medicare and Medicaid will enhance and simplify the coordination of your Medicare and Medicaid benefits. There are benefits to you if you are covered by the same health plan for Medicare and Medicaid. Some of these benefits include:• You receive better coordination of care through the same health plan.• You have one health plan and one number to call for questions about all of your

benefits.• You work with the same Care Coordinator for Medicare and Medicaid. This person

will work with you and your providers to make sure you get the care you need.

Value‑Added Service Additional DetailAdult dental: Available to members 21 and older (no prior authorization required)

Exam and cleaning twice per year, annual set of bitewing X‑rays, fillings, extractions, root canal or dentures (limited to $525 annually)

Adult vision: Available to members 21 and older (no prior authorization required)

Exam and $100 toward eyewear per year

Adult hearing: Available to members 21 and older (with prior authorization)

Exam and one hearing aid per year, unlimited visits for hearing aid fittings (limited to $500 annually)

Personal care attendant: Available (with prior authorization) to high‑risk members in a nursing facility

24 hours a day and seven days a week

Diabetes care: Available to members 21 and older (with prior authorization)

One pair of therapeutic shoes or two shoe inserts per year (limited to $150 annually)

Wellness rewards: Available to all members 21 and older (no prior authorization required)

Reloadable incentive card: $15 for diabetic dilated eye exam, $25 for wellness exam (to include HbA1c labs and LCL‑C screening), $15 woman’s mammography, $15 cervical cancer screening, $25 initial colonoscopy, $15 flu shot, and $25 prostate cancer screening


Value‑Added Service Additional DetailMedication Adherence Program for Chronic Illness: Available to members with chronic illness (no prior authorization is required)

Assists members with medications and help to ensure they are taking them as prescribed

Home‑delivered meals: Available to members 21 and older with prior authorization

Members (post‑discharge from inpatient stay) can receive two meals per day, tailored to their dietary needs and delivered to their home or community based setting for up to seven days

Weight management: Available to all members with prior authorization

12‑week program and six‑nutritionist‑counseling visits—provided through certified nutritionists

Memory care: Available to members diagnosed with dementia or Alzheimer’s disease (requires prior authorization)

Two‑door alarms and six window locks

Regional Wellness Centers: Available to all members

Regional Wellness Centers will be established in every region we serve. These centers will function as a one‑stop‑shop where members, caregivers, providers, community organizations and other stakeholders can use our meeting spaces, computers and Internet, or access our community resources database.

Community Health Workers: Available to all members (no prior authorization required)

Community Health Workers will be deployed throughout the community in each region to link members to: safe housing, local food markets, job opportunities and training, access to health care services, community based resources, transportation, recreational activities and other services. This assistance is available to all members.


Value‑Added Service Additional DetailHousing Solutions No Place Like Home Grants to facilitate

the transition from a nursing facility to a private residence. These grants provide for services including a home environmental assessment, home modifications, rent, and utility payment, hoarding intervention, cleaning services, handyman services, and pest control.

No Place Like Home Rental Assistance for members transitioning from a nursing facility into a private residence.

Members transitioning from a nursing facility into the community can access Aetna Better Communities benefits up to $5,000 per member. Benefits are funded through $200,000 in annual grants to Virginia 501(c)(3) non‑profits.

OnDemand Transportation (no Prior Authorization required)

Dramatically improves service, quality, and accessibility, offering our members realtime status and location updates through a phone application. Members, Care Coordinators and Discharge Planners can order via phone or through the mobile application. We also offer free rides to the pharmacy directly following a doctor’s appointment. There is no limit to rides for covered services: available to all members receiving transportation through managed care; no PA required.

Expanded Respite: Available to all members receiving respite services with Prior Authorization

10 additional respite hours per month

Free Cell Phone: Available to members 18 and older (no Prior Authorization required)

Free cell phone with 350 minutes per month, free unlimited texting and free calls to member services

If you choose Medicare fee‑for‑service or a Medicare plan other than our Medicare D‑SNP plan, we will work with your Medicare plan to coordinate your benefits.


How to Contact the Medicare State Health Insurance Assistance Program (SHIP)The State Health Insurance Assistance Program (SHIP) gives free health insurance counseling to people with Medicare. In Virginia, the SHIP is called the Virginia Insurance Counseling and Assistance Program (VICAP). You can contact the Virginia Insurance Counseling Assistance Program if you need assistance with your Medicare health insurance options. VICAP can help you understand your Medicare plan choices and answer your questions about changing to a new Medicare plan. VICAP is an independent program that is free and not connected to any CCC Plus health plans.

CALL 1‑800‑552‑3402 This call is free.TTY TTY users dial 711WRITE Virginia Insurance Counseling and Assistance Program

1610 Forest Avenue, Suite 100Henrico, Virginia 23229

EMAIL [email protected] http://www.vda.virginia.gov/vicap2.asp

3. How CCC Plus Works

Aetna Better Health contracts with doctors, specialists, hospitals, pharmacies, providers of long‑term services and supports, and other providers. These providers make up our provider network. You will also have a Care Coordinator. Your Care Coordinator will work closely with you and your providers to understand and meet your needs. Your Care Coordinator will also provide you with information about your covered services and the choices that are available to you. Refer to Your Care Coordinator in Section 4 of this handbook.

What are the Advantages of CCC PlusCCC Plus provides person‑centered supports and coordination to meet your individual needs. Some of the advantages of CCC Plus include:• You will have a care team that you help put together. Your care team may include

doctors, nurses, counselors, or other health professionals who are there to help you get the care you need.

• You will have a Care Coordinator. Your Care Coordinator will work with you and with your providers to make sure you get the care you need.

•


• You will be able to direct your own care with help from your care team and Care Coordinator.

• Your care team and Care Coordinator will work with you to come up with a care plan specifically designed to meet your health and/or long‑term support needs. Your care team will be in charge of coordinating the services you need. This means, for example: – Your care team will make sure your doctors know about all medicines you take so they can reduce any side effects. – Your care team will make sure your test results are shared with all your doctors and other providers so they can be kept informed of your health status and needs.

• Treatment choices that include preventive, rehabilitative, and community‑based care.

• An on‑call nurse or other licensed staff is available 24 hours per day, 7 days per week to answer your questions. We are here to help you. You can reach us by calling the number at the bottom of this page. Also, refer to Medical Advice Line Available 24 Hours a Day, 7 Days a Week in Section 5 of this handbook.

What are the Advantages of Choosing Aetna Better HealthThe care you need, when you need itWhy is Aetna Better Health of Virginia a great choice for Commonwealth Coordinated Care Plus members? We help you get the care you need, when you need it. Need a ride to the doctor? We have you covered with on‑demand transportation. Have a question about your benefits or care? Our nurses and Member Services reps are here for you 24 hours a day, 7 days a week. Just call 1‑855‑652‑8249.

Local presence, national strengthAetna Better Health of Virginia is committed to improving the health and lives of Virginia’s Medicaid population. We have been serving Virginians since 1996 as a managed care organization, and are fully accredited by the National Committee for Quality Assurance (NCQA). NCQA evaluates how well a health plan manages all parts of its delivery system in order to improve health care for its members. Aetna Better Health of Virginia is owned by Aetna, which provides services for over 3 million Medicaid members across the country.


Enhancing service, quality and accessibility with value‑added benefitsIn addition to our standard benefits, such as doctor and hospital coverage, immunizations and preventive exams, we also provide enhanced benefits and services, which include:

Benefit Description Amount you pay

Adult dental+ Exam, cleaning 2x/year, fillings, extrac‑tions, root canal or dentures (limit $525 per year)*

$0

Adult vision+ Exam and $100 per eyewear per year $0 Adult hearing+* Exam and one hearing aid per year,

unlimited hearing aid fittings (limit $500 per year)

$0

Diabetes care+* One pair of therapeutic shoes or two shoe inserts per year (limit $150 per year)

$0

Wellness rewards+ Incentive cards for diabetic dilated eye exam, diabetic wellness exam, mam‑mography, cervical cancer screening, initial colonoscopy, flu shot, prostate cancer screening

$0

Personal care atten‑dant*

Available to high‑risk members in nurs‑ing facility, 24 /7

$0

Employment resources We help members write resumes, pro‑vide interview coaching and link mem‑bers to employers

$0

Medication adherence program

For members with chronic illness $0

Home‑delivered meals+* After inpatient stay, members can re‑ceive 2 meals per day delivered to their home or community‑based setting for up to 7 days

$0

Housing resources We link members to resources for ac‑cessible housing, utility assistance and other resources including home modifi‑cations

$0


Benefit Description Amount you pay

Wellness centers Available to all members – with no lim‑its – as well as caregivers, providers and community organizations

$0

Weight management* 12‑week program and six nutritionist counseling visits

$0

Memory care* Members diagnosed with dementia and Alzheimer’s disease – 2 door alarms and 6 window alarms

$0

Free cell phone Free cell phone with 350 minutes per month, free unlimited texting, and free calls to Member Services. Available to members 18 and older

$0

+ Available to members age 21 and over

*These services require prior authorization. Your provider and the health plan will need to coordinate these services.

For a complete list of your benefits, please turn to page 64.

Continuity of Care PeriodIf Aetna Better Health is new for you, you can keep seeing the doctors you go to now for the first 90 days. You can also keep getting your authorized services for the duration of the authorization or for 90 days after you first enroll, whichever is sooner. After 90 days in our plan, you will need to see doctors and other providers in the Aetna Better Health network. A network provider is a provider who contracts and works with our health plan.

If you are in a nursing facility at the start of the CCC Plus Program, you may choose to • Remain in the facility as long as you continue to meet the Virginia DMAS’ criteria for

nursing facility care, • Move to a different nursing facility, or • Receive services in your home or other community based setting.

Talk to your Care Coordinator if you want to learn more about these options.


If You Have Other CoverageMedicaid is the payer of last resort. This means that if you have another insurance, are in a car accident, or if you are injured at work, your other insurance or Workers Compensation has to pay first.

We have the right and responsibility to collect payment for covered Medicaid services when Medicaid is not the first payer. We will not attempt to collect any payment directly from you. Contact Member Services if you have other insurance so that we can best coordinate your benefits. Your Care Coordinator will also work with you and your other health plan to coordinate your services.

4. Your Care Coordinator

You have a dedicated Care Coordinator who can help you to understand your covered services and how to access these services when needed. Your Care Coordinator will also help you to work with your doctor and other health care professionals (such as nurses and physical therapists), to provide a health risk assessment, and develop a care plan that considers your needs and preferences. We provide more information about the health risk assessment and the care plan below.

How Your Care Coordinator Can Help Your care coordinator serves as your single point of contact and will assess, arrange, and monitor all care services provided by other care providers. Your care coordinator will work closely with you to manage your care. If you would like to change your care coordinator, please call Member Services at 1‑855‑652‑8249.

Your Care Coordinator can: • Answer questions about your health care• Provide assistance with appointment scheduling • Answer questions about getting any of the services you need. For example:

behavioral health services, transportation, and long‑term services and supports (LTSS) – Long‑term services and supports (LTSS) are a variety of services and supports that help older individuals and individuals with disabilities meet their daily needs for assistance, improve the quality of their lives, and facilitate maximum independence. Examples include personal assistance services (assistance with bathing, dressing, and other basic activities of daily life and self‑care), as well as support for everyday tasks such as meal preparation, laundry, and shopping. LTSS are provided over a long period, usually in homes and communities, but also in nursing facilities.


• Help with arranging transportation to your appointments when necessary. If you need a ride to receive a Medicaid covered service and cannot get there, non‑emergency transportation is covered. Just call 1‑855‑652‑8249 (toll‑free) or call your Care Coordinator for assistance.

• Answer questions you may have about your daily health care and living needs including these services: – Skilled nursing care – Physical therapy – Occupational therapy – Speech therapy – Home health care – Personal care services – Behavioral health services – Services to treat addiction – Other services that you need

What is a Health Risk AssessmentWithin the first few weeks after you enroll with Aetna Better Health, your Care Coordinator will meet with you to ask you some questions about your health, needs, and choices. Your Care Coordinator will talk with you about any medical, behavioral, physical, and social service needs that you may have. This meeting may be in‑person or by phone and is known as a health risk assessment (HRA). A HRA is a complete assessment of your medical, behavioral, social, emotional, and functional status. Your Care Coordinator generally completes the HRA within the first 30 to 60 days of your enrollment with us depending upon the type of services that you require. This health risk assessment will enable your Care Coordinator to understand your needs and help you get the care that you need.

What is a Care PlanA care plan includes the types of health services that are needed and how you will get them. It is based on your health risk assessment. After you and your Care Coordinator complete your health risk assessment, your care team will meet with you to talk about what health and/or long‑term services and supports you need and want as well as your goals and preferences. Together, you and your care team will make a personalized care plan, specific to your needs. (This is also referred to as a person‑centered care plan.) Your care team will work with you to update your care plan when the health services you need or choose change, and at least once per year.


How to Contact Your Care CoordinatorYou can reach your care coordinator by calling 1‑855‑652‑8249.

CALL 1‑855‑652‑8249 This call is free.Monday – Friday 8am – 5pm We have free interpreter services for people who do not speak English.

TTY 1‑800‑828‑1120 This call is free. Monday – Friday 8am – 5pm

FAX 1‑844‑459‑6680WRITE Aetna Better Health of Virginia

ATTN: Care Management9881 Mayland DriveRichmond, VA 23233

EMAIL [email protected] www.aetnabetterhealth.com/virginia

5. Help From Member Services

Our Member Services Staff are available to help you if you have any questions about your benefits, services, or procedures or have a concern about Aetna Better Health. Member Services is available 24/7/365.

How to Contact Aetna Better Health Member Services

CALL 1‑855‑652‑8249 This call is free.We are available 24 hours/7 days a week We have free interpreter services for people who do not speak English.

TTY 1‑800‑828‑1120 This call is free. We are available 24 hours/7 days a week

FAX 1‑866‑207‑8901

WRITE Aetna Better Health of VirginiaATTN: Member Services9881 Mayland DriveRichmond, VA 23233

EMAIL [email protected]

WEBSITE www.aetnabetterhealth.com/virginia


How Member Services Can HelpMember Services can: • Answer questions you have about Aetna Better Health• Answer questions you have about claims, billing or your Member ID Card• Help you find a doctor or see if a doctor is in Aetna Better Health’s network• Help you change your Primary Care Physician (PCP)• Provide information on coverage decisions about your health care services (including

medications) – A coverage decision about your health care is a decision about:• your benefits and covered services, or• the amount we will pay for your health services.

• Provide information on how you can submit an appeal about a coverage decision on your health care services (including medications). An appeal is a formal way of asking us to review a decision we made about your coverage and asking us to change it if you think we made a mistake. (See Your Right to Appeal in Section 15 of this handbook).

• Complaints about your health care services (including medications). You can make a complaint about us or any provider (including a non‑network or network provider). A network provider is a provider who contracts and works with the health plan. You can also make a complaint about the quality of the care you received to us or to the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608. (See Your Right to File a Complaint in Section 15 of this handbook).

Medical Advice Line Available 24 Hours a Day, 7 Days a WeekIf you are unable reach your Care Coordinator, you can reach a nurse or behavioral health professional 24 hours a day, 7 days a week to answer your questions toll‑free at: 1‑855‑652‑8249.

We encourage our members to work with their PCP for their health care needs. However, if you have a medical question and you are not sure what to do, call our 24‑hour nurse helpline. Our nurse helpline can help answer specific questions or give you advice on what to do when you need health care, such as calling your PCP, making an appointment or going immediately to the Emergency Room.

CALL 1‑855‑652‑8249 This call is free.Available 24 hours a day, 7 days a week We have free interpreter services for people who do not speak English.

TTY 1‑800‑828‑1120 This call is free.


Behavioral Health Crisis Line Available 24 Hours a Day, 7 Days a WeekContact Aetna Better Health if you do not know how to get services during a crisis. We will help find a crisis provider for you. Call 1‑855‑652‑8249. If you have thoughts about harming yourself or someone else, you should: • Get help right away by calling 911.• Go to the closest hospital for emergency care.



Addiction and Recovery Treatment Services (ARTS) Advice Line Available 24 Hours a Day, 7 Days a WeekIf you are unable reach your Care Coordinator, you can reach an ARTS health professional 24 hours a day, 7 days a week to answer your questions at 1‑855‑652‑8249. The call is free.



If You Do Not Speak EnglishWe can provide you with translation services. Aetna Better Health Member Services has employees who speak your language and we are able to access interpreter services. We also have written information in many languages for our Members. Currently written materials are available in English and Spanish. If you need interpretation, please call Member Services (at no charge) at 1‑855‑652‑8249 and request to speak to an interpreter or request written materials in your language.

If You Have a Disability and Need Assistance in Understanding Information or Working with Your Care CoordinatorWe provide reasonable accommodations to people with disabilities in compliance with the Americans with Disabilities Act. This includes but is not limited to accessible communications (such as a qualified sign language interpreter), braille or large print materials, etc. If you need a reasonable accommodation, please call Member Services (at no charge) at 1‑855‑652‑8249 to ask for the help you need.

If You Have Questions About Your Medicaid Eligibility


If you have questions about your Medicaid eligibility, contact your Medicaid eligibility worker at the Department of Social Services in the city or county where you live. If you have questions about the services you get under Aetna Better Health, call Member Services at the phone number below.

6. How to Get Care and Services

How to Get Care from Your Primary Care PhysicianYour Primary Care PhysicianA Primary Care Physician (PCP) is a doctor selected by you who meets state requirements and is trained to give you basic medical care. You will usually see your PCP for most of your routine health care needs. Your PCP will work with you and your Care Coordinator to coordinate most of the services you get as a Member of our plan. Coordinating your services or supplies includes checking or consulting with other plan providers about your care. If you need to see a doctor other than your PCP, you may need a referral (authorization) from your PCP. You may also need to get approval in advance from your PCP before receiving certain types of covered services or supplies. In some cases, your PCP will need to get authorization (prior approval) from us. Since your PCP will provide and coordinate your medical care, you should have all of your past medical records sent to your PCP’s office. Contact Member Services or your Care Coordinator with any questions you have about getting your medical records transferred to your PCP or about your care and services.

Choosing Your PCPNew Members have the right to choose a PCP in our network soon after joining Aetna Better Health by contacting Member Services at the number listed at the bottom of the page or accessing our member portal at www.aetnabetterhealth.com/virginia. If you do not already have a PCP you must request one prior to the 25th day of the month before your effective enrollment date, or else Aetna Better Health may assign you a PCP. You have the right to change your PCP at any time by calling Member Services at the number listed at the bottom of this page.

If you do not have a PCP in our network, we can help you find a highly qualified PCP in your community. For help locating a provider you can use our on‑line provider directory at: www.aetnabetterhealth.com/virginia. The provider directory includes a list of all of the doctors, clinics, hospitals, labs, specialists, long‑term services and supports providers, and other providers who work with Aetna Better Health. The directory also includes information on the accommodations each provider has for individuals who have disabilities or who do not speak English. We can also provide you with a paper copy of the provider directory. You can also call Member Services at the number on the bottom of this page or call your Care Coordinator for assistance.


You may want to find a doctor:• Who knows you and understands your health condition,• Who is taking new patients,• Who can speak your language, or• Who has appropriate accommodations for people with physical or other disabilities.

If you have a disability or a chronic illness, you can ask us if your specialist can be your PCP. We also contract with Federally Qualified Health Centers (FQHC) that provide primary and specialty care. Another clinic can also act as your PCP if the clinic is a network provider.

Women can also choose an OB/GYN for women’s health issues. These include routine check‑ups, follow‑up care if there is a problem, and regular care during a pregnancy. Women do not need a PCP referral to see an OB/GYN provider in our network.

To find a participating provider or specialist, go to our website at www.aetnabetterhealth.com/virginia. Select “Find a Provider” at the top of the page. You can search by zip code or county and state, and even narrow results down to a particular specialty if needed. If you need help finding a provider or specialists near you.

If You have Medicare, Tell us About Your PCPIf you have Medicare, you do not have to choose a PCP in Aetna Better Health’s network. Simply call Member Services or your Care Coordinator to let us know the name and contact information for your PCP. We will coordinate your care with your Medicare assigned PCP.

If Your Current PCP is not in Our NetworkIf you do not have Medicare, you need to choose a PCP that is in Aetna Better Health’s network. You can continue to see your current PCP for up to 90 days even if they are not in the Aetna Better Health’s network. During the first 90 days of your enrollment with us, your Care Coordinator can help you find a PCP in our network. At the end of the 90‑day period, if you do not choose a PCP in the Aetna Better Health network, we will assign a PCP to you.

Changing Your PCPYou may call Member Services to change your PCP at any time to another PCP in our network. Also, it is possible that your PCP might leave our network. We will tell you within 15 days from when we know about this. We can help you find a new PCP.

You can change your PCP on our secure member web portal at www.aetnabetterhealth.com/virginia. Or you can call Member Services at 1‑855‑652‑8249 (TTY/TDD: 711 or 1‑800‑828‑1120). You need to do this before you visit your new doctor. Your change will happen the first day of the month. If you make


your change by the 20th day of the month, you can use your new PCP by the 1st of the next month.

Getting an Appointment with Your PCPYour PCP will take care of most of your health care needs. Call your PCP to make an appointment. If you need care before your first appointment, call your PCP’s office to ask for an earlier appointment. If you need help making an appointment, call Member Services at the number below.

Appointment StandardsYou should be able to get an appointment with your PCP within the same amount of time as any other patient seen by the PCP. Expect the following times to see a provider: • For an emergency ‑ immediately.• For urgent care and office visits with symptoms – within 24 hours of request.• For routine primary care visit – within 30 calendar days.

If you are pregnant, you should be able to make an appointment to see an OB/GYN as follows:• First trimester (first 3 months) ‑ Within fourteen (14) calendar days of request.• Second trimester (3 to 6 months) ‑ Within seven (7) calendar days of request.• Third trimester (6 to 9 months) ‑ Within five (5) business days of request.• High Risk Pregnancy ‑ Within three (3) business days or immediately if an emergency

exists.

If you are unable to receive an appointment within the times listed above, call Member Services at the number below and they will help you get the appointment.

How to Get Care From Network ProvidersOur provider network includes access to care 24 hours a day 7 days per week and includes hospitals, doctors, specialists, urgent care facilities, nursing facilities, home and community based service providers, early intervention providers, rehabilitative therapy providers, addiction and recovery treatment services providers, home health and hospice providers, durable medical equipment providers, and other types of providers. Aetna Better Health provides you with a choice of providers and they are located so that you do not have to travel very far to see them. There may be special circumstances where longer travel time is required; however, that should be only on rare occasions.

Travel Time and Distance StandardsAetna Better Health will provide you with the services you need within the travel time and distance standards described in the table below. These standards apply for services that you travel to in order to receive care from network providers. These


standards do not apply to providers who provide services to you at home. If you live in an urban area, you should not have to travel more than 30 miles or 45 minutes to receive services. If you live in a rural area, you should not have to travel more than 60 miles or 75 minutes to receive services.

Member Travel Time & Distance StandardsStandard Distance Time

Urban• PCP• Specialists and other providers

15 Miles30 Miles

30 Minutes45 Minutes

Rural• PCP• Specialists and other providers

30 Miles60 Miles

45 Minutes75 Minutes

AccessibilityAetna Better Health wants to make sure that all providers and services are as accessible (including physical and geographic access) to individuals with disabilities as they are to individuals without disabilities. If you have difficulty getting an appointment with a provider, or accessing services because of a disability, contact Member Services at the telephone numbers below for assistance.

What are “Network Providers”Aetna Better Health’s network providers include:• Doctors, nurses, and other health care professionals that you can go to as a Member

of our plan; • Clinics, hospitals, nursing facilities, and other places that provide health services in

our plan;• Early intervention providers, home health agencies and durable medical equipment

suppliers;• Long‑term services and supports (LTSS) providers including nursing facilities,

hospice, adult day health care, personal care, respite care, and other LTSS providers.

Network providers have agreed to accept payment from our plan for covered services as payment in full.

What are “Network Pharmacies”Network pharmacies are pharmacies (drug stores) that have agreed to fill prescriptions for our Members. Use the Provider and Pharmacy Directory to find the network pharmacy you want to use.

Except during an emergency, you must fill your prescriptions at one of our network pharmacies if you want our plan to help you pay for them. Call Member Services at the number at the bottom of the page for more information. Both Member Services


and Aetna Better Health’s website can give you the most up‑to‑date information about changes in our network pharmacies and providers.

What are Specialists

If you need care that your PCP cannot provide, your PCP may refer you to a specialist. Most of the specialists are in Aetna Better Health’s network. A specialist is a doctor who provides health care for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:• Oncologists care for patients with cancer.• Cardiologists care for patients with heart problems.• Orthopedists care for patients with bone, joint, or muscle problems.

If you need to see a specialist for ongoing care, your PCP may be able to refer you for a specified number of visits or length of time (known as a standing referral). If you have a standing referral, you will not need a new referral each time you need care. If you have a disabling condition or chronic illnesses, you can ask us if your specialist can be your PCP.

To find a participating provider or specialist, go to our website at www.aetnabetterhealth.com/virginia. Select “Find a Provider” at the top of the page. You can search by zip code or county and state, and even narrow results down to a particular specialty if needed. If you need help finding a provider or specialist near you, call Member Services at 1‑855‑652‑8249 (TTY/TDD: 711 or 1‑800‑828‑1120)

We do not require you to get a referral to your PCP before you see another Aetna Better Health in‑network provider. You still should call your PCP or care coordinator to let them know you are going to the other provider. This helps your PCP coordinate your care.

Utilization ManagementWe know that you want to feel sure that you are getting the most appropriate health care and services in the right place. This is called utilization management (UM). Our UM staff uses clinical review criteria, practice guidelines and written policies to make UM decisions. UM decisions are based on these reasons:• Services requires are medical needed (also called medically necessary)• Services requested are covered

You can call us at Member Services at 1‑855‑652‑8249 with questions about our UM program. Member services may transfer your call to the UM department for a staff member to help you. After business hours, you may be transferred to our after‑hours call center. Someone will take your message. We’ll call you the next business day.


Utilization management affirmative statement about incentivesWe understand members want to feel confident they are receiving the health care and services that are best for them. We have policies our practitioners and providers follow to ensure you receive the right healthcare.

We do not use incentives to encourage barriers to care and/or services, or to reward inappropriate restrictions of care. This is called an affirmative statement.

We want to let you know that:• Utilization management decisions are based only on appropriateness of care and

services and whether they are covered• We do not reward or pay our network of providers or employees to deny reviews• No financial incentives are offered to encourage underutilization

The UM staff uses clinical review criteria, practice guidelines and written policies to make these decisions. Utilization decisions are based on the following reasons:• Services are medically needed.• Services are covered in the member’s plan.

We want to ensure that each member receives the right healthcare. If you need help understanding this information call Member Services at 1‑855‑652‑8249

We must preauthorize some health care, drugs, and supplies you get. We will give preauthorization to providers when you need health care, drugs or supplies that are medically needed and are listed below. Your doctor needs to call us for approval at least 3 working days before your scheduled care. We may ask to see written notes showing that your care is medically needed before we preauthorize it. Our staff is available from 8 am and 5 pm ET. If you have any questions, call Member Services at 1‑855‑652‑8249.

You must get your first service on the date or within the dates listed on your preauthorization. If you can’t get the care on the date or within the dates listed on your preauthorization or you need more visits, you must call your doctor or care coordinator. Your doctor will call us to change the preauthorized dates. Preauthorization’s are good for a specific amount of time. The preauthorization does not go past your last covered date.

Your preauthorization for care is for a specific problem or sometimes for a set number of visits. If you run out of visits and still need more, call your doctor or care coordinator. Your doctor must call us to add more visits.


Preauthorization is required before the date you get care for the services listed below:

• Durable Medical Equipment (DME) • Genetic testing• Home based services including personal

care • Imaging (scans)

• Injectables • Inpatient services • Neuropsychological testing • Orthotics/Prosthetics • Outpatient surgery • Psychological testing • Services from providers not in your

network • Sleep studies

• Therapies • Nuclear Radiology• Transplant consultations, evaluations and

testing/transplant procedures

If Your Provider Leaves Our PlanA network provider you are using might leave our plan. If one of your providers does leave our plan, you have certain rights and protections that are summarized below:• Even though our network of providers may change during the year, we must give

you uninterrupted access to qualified providers.• When possible, we will give you at least 15 days’ notice so that you have time to

select a new provider.• We will help you select a new qualified provider to continue managing your health

care needs.• If you are undergoing medical treatment, you have the right to ask, and we will work

with you to ensure, that the medically necessary treatment you are getting is not interrupted.

• If you believe we have not replaced your previous provider with a qualified provider or that your care is not being appropriately managed, you have the right to file a complaint or request a new provider.

• If you find out one of your providers is leaving our plan, please contact your Care Coordinator so we can assist you in finding a new provider and managing your care.

If your provider leaves our provider network, you may continue to receive covered services from this provider in the following cases:• You may receive covered services from your PCP for a period of up to 90 days

after the date your PCP has given or received from us, a notice that his or her participation status in Aetna Better Health is ending. This can only take place if your PCP remains in the Aetna Better Health service area and is open to see patients.


• You may receive covered services from non‑PCP providers other than your PCP for a period of at least 90 days if you were in an active course of treatment with an Aetna Better Health provider before the provider’s notice of termination from our provider network. You must make a request to continue receiving health care services from that provider.

You are able to receive care for extended periods under the following circumstances:• If you have entered your second trimester of pregnancy at the time your provider’s

participation is terminated and your services from that provider are directly related to the delivery through postpartum care.

• If you have a medical prognosis of life expectancy that is 6 months or less, you may continue to receive treatment from such provider for the remainder of your life for care directly related to the treatment of the terminal illness.

The continuity of care options described above are not available if your provider is terminated for cause or if you are no longer an Aetna Better Health member. We will pay the provider for covered services you receive as described above according to our agreement with the provider.

If your provider leaves the network call, Member Services for help at 1‑855‑652‑8249 (TTY/TDD: 711 or 1‑800‑828‑1120).

How to Get Care from Out‑of‑Network ProvidersYour doctor may tell you that you need to see a doctor or other health care provider who is not an Aetna Better Health in‑network provider. If so, he or she must send in writing the health information we need to review the request. Our staff will review the information. You can go to a provider outside the Aetna Better Health network only if: (1) the care is needed; and (2) there are no Aetna Better Health in‑network providers who can give you the care you need. We have the right to say where you can receive services when no Aetna Better Health provider can give you the care you need. Your care must be preauthorized before your visit. The doctor that wants to give you care should ask for preauthorization. When you receive care outside our network it must be approved by us first, there is no cost to you. If you have questions, call Member Services at the number listed below. If we do not have a specialist in the Aetna Better Health network to provide the care you need, we will get you the care you need from a specialist outside of the Aetna Better Health network. We will also get you care outside of the Aetna Better Health network in any of the following circumstances: • When Aetna Better Health has approved a doctor out of its established network; • When emergency and family planning services are rendered to you by an out of

network provider or facility;• When you receive emergency treatment by providers not in the network;• When the needed medical services are not available in Aetna Better Health’s

network;


• When Aetna Better Health cannot provide the needed specialist within the distance standard of more than 30 miles in urban areas or more than 60 miles in rural areas;

• When the type of provider needed and available in Aetna Better Health’s network does not, because of moral or religious objections, furnish the service you need;

• Within the first 90 calendar days of your enrollment, when your provider is not part of Aetna Better Health’s network but has treated you in the past; and,

• If you are in a nursing facility when you enroll with Aetna Better Health and the nursing facility is not in Aetna Better Health’s network.

If your PCP or Aetna Better Health refer you to a provider outside of our network, you are not responsible for any of the costs, except for your patient pay towards long‑term services and supports. See Section 13 of this handbook for information about what a patient pay is and how to know if you have one.

Care From Out‑of‑State ProvidersAetna Better Health is not responsible for services you obtain outside Virginia except under the following circumstances:• Necessary emergency or post‑stabilization services;• Where it is a general practice for those living in your locality to use medical

resources in another State; and,• The required services are medically necessary and not available in‑network and

within the Commonwealth of Virginia.

Network Providers Cannot Bill You DirectlyNetwork providers must always bill Aetna Better Health. Doctors, hospitals, and other providers in our network cannot make you pay for covered services. They also cannot charge you if we pay for less than what the provider charged us; this is known as “balanced billing.” This is true even if we pay the provider less than the provider charged for a service. If we decide not to pay for some charges, you still do not have to pay them.

If You Receive a Bill for Covered ServicesIf you are billed for any of the services covered by our plan, you should not pay the bill. If you do pay the bill, Aetna Better Health may not be able to pay you back.

Whenever you get a bill from a network provider or for services that are covered outside of the network (example emergency or family planning services) send us the bill. We will contact the provider directly and take care of the bill for covered services.

If You Receive Care From Providers Outside of the United StatesOur plan does not cover any care that you get outside the United States.


7. How to Get Care for Emergencies

What is an EmergencyYou are always covered for emergencies. An emergency is a sudden or unexpected illness, severe pain, accident, or injury that could cause serious injury or death if it is not treated immediately.

What to do in an EmergencyCall 911 at once! You do not need to call Aetna Better Health first. You do not need an authorization or a referral for emergency services.

Go to the closest hospital. Calling 911 will help you get to a hospital. You can use any hospital for emergency care, even if you are in another city or state. If you are helping someone else, try to stay calm.

Tell the hospital that you are an Aetna Better Health Member. Ask them to call Aetna Better Health at the number on the back of your CCC Plus ID Card.

What is a Medical EmergencyThis is when a person thinks he or she must act quickly to prevent serious health problems. It includes symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn’t get immediate medical attention, you believe that it could cause:• serious risk to your health; or• serious harm to bodily functions; or• serious dysfunction of any bodily organ or part; or• in the case of a pregnant woman in active labor, meaning labor at a time when either

of the following would occur: – There is not enough time to safely transfer you to another hospital before delivery, or – The transfer may pose a threat to your health or safety or to that of your unborn child.

What is a Behavioral Health EmergencyA behavioral health emergency is when a person thinks about or fears they might hurt themselves or hurt someone else.

Examples of Non‑EmergenciesExamples of non‑emergencies are: colds, sore throat, upset stomach, minor cuts and bruises, or sprained muscles. If you are not sure, call your PCP or the Aetna Better Health’s 24/7 medical advice line at: 1‑855‑652‑8249.


If You Have an Emergency When Away From HomeYou or a family Member may have a medical or a behavioral health emergency away from home. You may be visiting someone outside Virginia. While traveling, your symptoms may suddenly get worse. If this happens, go to the closest hospital emergency room. You can use any hospital for emergency care. Show them your Aetna Better Health card. Tell them you are in Aetna Better Health’s program.

What is Covered if You Have an EmergencyYou may receive covered emergency care whenever you need it, anywhere in the United States. If you need an ambulance to get to the emergency room, our plan covers the ambulance transportation. If you have an emergency, we will talk with the doctors who give you emergency care. Those doctors will tell us when your medical emergency is complete.

Notifying Aetna Better Health About Your EmergencyNotify your doctor and Aetna Better Health as soon as possible about the emergency within 48 hours if you can. However, you will not have to pay for emergency services because of a delay in telling us. We need to follow up on your emergency care. Your Care Coordinator will assist you in getting the correct services in place before you are discharged to ensure that you get the best care possible. Please call your Care Coordinator at 1‑855‑652‑8249. This number is also listed on the back of Aetna Better Health’s Member card.

After an EmergencyAetna Better Health will provide necessary follow‑up care, including through out of network providers if necessary, until your physician says that your condition is stable enough for you to transfer to an in‑network provider, or for you to be discharged. If you get your emergency care from out‑of‑network providers, we will try to get network providers to take over your care as soon as possible after your physician says you are stable. You may also need follow‑up care to be sure you get better. Your follow‑up care will be covered by our plan.

If You Are HospitalizedIf you are hospitalized, a family Member or a friend should contact Aetna Better Health as soon as possible. By keeping Aetna Better Health informed, your Care Coordinator can work with the hospital team to organize the right care and services for you before you are discharged. Your Care Coordinator will also keep your medical team including your home care services providers informed of your hospital and discharge plans.


If it Wasn’t a Medical EmergencySometimes it can be hard to know if you have a medical emergency. You might go in for emergency care, and the doctor may say it wasn’t really a medical emergency. As long as you reasonably thought your health was in serious danger, we will cover your care. However, after the doctor says it was not an emergency, we will cover your additional care only if you follow the General Coverage Rules described in Section 10 of this handbook.

8. How to Get Urgently Needed Care

What is Urgently Needed CareUrgently needed care is care you get for a non‑life threatening, sudden illness, injury, or condition that isn’t an emergency but needs care right away. For example, you might have an existing condition that worsens and you need to have it treated right away. Other examples of urgently needed care include sprains, strains, skin rashes, infection, fever, flu, etc. In most situations, we will cover urgently needed care only if you get this care from a network provider.

You can find a list of urgent care centers we work with in our Provider and Pharmacy Directory, available on our website at: www.aetnabetterhealth.com/virginia.

9. How to Get Your Prescription Drugs

This Section explains rules for getting your outpatient prescription drugs. These are drugs that your provider orders for you that you get from a pharmacy or drug store.

Rules for Aetna Better Health’s Outpatient Drug CoverageAetna Better Health will usually cover your drugs as long as you follow the rules in this Section.1. You must have a doctor or other authorized provider write your prescription.

This person often is your primary care physician (PCP). It could also be another provider if your primary care physician has referred you for care.

2. You generally must use a network pharmacy to fill your prescription.3. Your prescribed drug must be on Aetna Better Health’s List of Covered Drugs. If

it is not on the List of Covered Drugs, we may be able to cover it by giving you a service authorization.

4. Your drug must be used for a medically accepted indication. This means that the use of the drug is either approved by the Food and Drug Administration or supported by certain medical reference books.

5. If you have Medicare, most of your drugs are covered through your Medicare carrier. We cannot pay for any drugs that are covered under Medicare Part D,


including copayments. 6. Aetna Better Health can provide coverage for coinsurance and deductibles on

Medicare Part A and B drugs. These include some drugs given to you while you are in a hospital or nursing facility.

Getting Your Prescriptions FilledIn most cases, Aetna Better Health will pay for prescriptions only if they are filled at Aetna Better Health’s network pharmacies. A network pharmacy is a drug store that has agreed to fill prescriptions for our Members. You may go to any of our network pharmacies.

To find a network pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Member Services at the number at the bottom of the page or your Care Coordinator.

To fill your prescription, show your Member ID Card at your network pharmacy. If you have Medicare, show your Medicare Part D and Aetna Better Health ID cards. The network pharmacy will bill Aetna Better Health for the cost of your covered prescription drug. If you do not have your Member ID Card with you when you fill your prescription, ask the pharmacy to call Aetna Better Health to get the necessary information.

If you need help getting a prescription filled, you can contact Member Services at the number at the bottom of the page or call your Care Coordinator.

List of Covered DrugsAetna Better Health has a List of Covered Drugs that are selected by Aetna Better Health of Virginia with the help of a team of doctors and pharmacists. The Aetna Better Health of Virginia List of Covered Drugs also includes all of the drugs on the DMAS Preferred Drug List (PDL). The List of Covered Drugs can be found at www.aetnabetterhealth.com/virginia. The List of Covered Drugs tells you which drugs are covered by Aetna Better Health and also tells you if there are any rules or restrictions on any drugs, such as a limit on the amount you can get.

You can call Member Services to find out if your drugs are on the List of Covered Drugs or check on‑line at www.aetnabetterhealth.com/virginia or we can mail you a paper copy of the List of Covered Drugs. The List of Covered Drugs may change during the year. To get the most up‑to‑date List of Covered Drugs, visit www.aetnabetterhealth.com/virginia or call Member Services at the number listed below.

To find out if a drug you are taking is on the Drug List, you can:• Visit the plan’s website at www.aetnabetterhealth.com/virginia. The Drug List

on the website is always the most current one.


• Call Member Services to find out if a drug is on the plan’s Drug List or to ask for a copy of the list.

The plan does not cover all prescription drugs. Some drugs are not on the Drug List because the law does not allow the plan to cover those drugs. In other cases, we have decided not to include a drug on the Drug List. Aetna Better Health Plan will not pay for the drugs listed in this section. These are called excluded drugs. If you get a prescription for an excluded drug, you must pay for it yourself. If you think we should pay for an excluded drug because of your case, you can file an appeal. (To learn how to file an appeal, see Section 15.)

We will generally cover a drug on Aetna Better Health’s List of Covered Drugs as long as you follow the rules explained in this Section. You can also get drugs that are not on the list when medically necessary. Your physician may have to obtain a service authorization from us in order for you to receive some drugs.

Limits for Coverage of Some DrugsFor certain prescription drugs, special rules limit how and when we cover them. In general, our rules encourage you to get a drug that works for your medical condition and that is safe and effective, and cost effective.

If there is a special rule for your drug, it usually means that you or your provider will have to take extra steps for us to cover the drug. For example, your provider may need to request a service authorization for you to receive the drug. We may or may not agree to approve the request without taking extra steps. Refer to Service Authorization and Benefit Determination and Service Authorizations and Continuity of Care in Section 14 of this handbook.

If Aetna Better Health is new for you, you can keep getting your authorized drugs for the duration of the authorization or for 90 days after you first enroll, whichever is sooner. Refer to Continuity of Care Period in Section 3 of this handbook.

If we deny or limit coverage for a drug, and you disagree with our decision, you have the right to appeal our decision. Refer to Your Right to Appeal in Section 15 of this handbook. If you have any concerns, contact your Care Coordinator. Your Care Coordinator will work with you and your PCP to make sure that you receive the drugs that work best for you.

Getting Approval in AdvanceFor some drugs, you or your doctor must get a service authorization approval from Aetna Better Health before you fill your prescription. If you don’t get approval, Aetna Better Health may not cover the drug.


Trying a Different Drug FirstWe may require that you first try one (usually less‑expensive) drug (before we will cover another (usually more‑expensive) drug for the same medical condition. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, then we will cover Drug B. This is called step therapy.

Quantity LimitsFor some drugs, we may limit the amount of the drug you can have. This is called a quantity limit. For example, the plan might limit how much of a drug you can get each time you fill your prescription.

To find out if any of the rules above apply to a drug your physician has prescribed, check the List of Covered Drugs. For the most up‑to‑date information, call Member Services or check our website at www.aetnabetterhealth.com/virginia.

Emergency SupplyThere may be an instance where your medication requires a service authorization, and your prescribing physician cannot readily provide authorization information to us, for example over the weekend or on a holiday. If your pharmacist believes that your health would be compromised without the benefit of the drug, we may authorize a 72‑hour emergency supply of the prescribed medication. This process provides you with a short‑term supply of the medications you need and gives time for your physician to submit a service authorization request for the prescribed medication.

Non Covered DrugsBy law, the types of drugs listed below are not covered by Medicare or Medicaid:• Drugs used to promote fertility;• Drugs used for cosmetic purposes or to promote hair growth;• Drugs used for the treatment of sexual or erectile dysfunction, such as Viagra®,

Cialis®, Levitra®, and Caverject®, unless such agents are used to treat a condition other than sexual or erectile dysfunction, for which the agents have been approved by the FDA;

• Drugs used for treatment of anorexia, weight loss, or weight gain;• All DESI (Drug Efficacy Study Implementation) drugs as defined by the FDA to be less

than effective, including prescriptions that include a DESI drug;• Drugs that have been recalled; • Experimental drugs or non‑FDA‑approved drugs; and,• Any drugs marketed by a manufacturer who does not participate in the Virginia

Medicaid Drug Rebate program.


Changing PharmaciesIf you need to change pharmacies and need a refill of a prescription, you can ask your pharmacy to transfer the prescription to the new pharmacy. If you need help changing your network pharmacy, you can contact Member Services at the number at the bottom of the page or your Care Coordinator.

If the pharmacy you use leaves Aetna Better Health’s network, you will have to find a new network pharmacy. To find a new network pharmacy, you can look in the Provider and Pharmacy Directory, visit our website, or contact Member Services at the number at the bottom of the page or your Care Coordinator. Member Services can tell you if there is a network pharmacy nearby.

What if You Need a Specialized PharmacySometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include pharmacies that supply drugs for home infusion therapy or residents of a long‑term care facility, such as a nursing facility.

Usually, nursing facilities have their own pharmacies. If you are a resident of a nursing facility, we must make sure you can get the drugs you need at the nursing facility’s pharmacy. If you have any problems getting your drug benefits in a nursing facility, please contact your Care Coordinator or Member Services at the number at the bottom of the page.

Can You Use Mail‑Order Services to Get Your DrugsFor certain kinds of drugs, you can use the plan’s network mail‑order services. Generally, the drugs available through mail order are drugs that you take on a regular basis for a chronic or long‑term medical condition. The drugs available through our plan’s mail‑order service are marked as mail‑order drugs in our Drug List.

Our plan’s mail‑order service allows you to order up to a 90‑day supply. A 90‑day supply has the same copay as one‑month supply.

To get order forms and information about filling your prescriptions by mail, call Member Services or your care coordinator at 1‑855‑652‑8249 (TTY: 711) 24 hours a day, 7 days a week to request a mail order form, or you can register online with CVS Caremark at www.caremark.com.

Can You Get a Long‑Term Supply of DrugsYou can get a long‑term supply of maintenance drugs our plan’s Drug List. Maintenance drugs are drugs that you take on a regular basis, for chronic or long‑term medical condition.


Some network pharmacies allow you to get a long‑term supply of maintenance drugs. A 90‑day supply has the same copay as a one‑month supply. The Provider and Pharmacy Directory tells you which pharmacies can give you a long‑term supply of maintenance drugs. You can also call Member Services for more information.

For certain kinds of drugs, you can use the plan’s network mail‑order services to get a long‑term supply of maintenance drugs. See the section above to learn about mail‑order services.

Can You Use a Pharmacy that is Not in Aetna Better Health’s NetworkGenerally, Aetna Better Health pays for drugs filled at an out‑of‑network pharmacy only when you are not able to use a network pharmacy. We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.

We will pay for prescriptions filled at an out‑of‑network pharmacy in the following cases:• If you get a prescription in connection with emergency care.• If you get a prescription in connection with urgently needed care when network

pharmacies are not available.• If you are unable to get a covered prescription drug in a timely manner within our

service area because there is no network pharmacy with 24‑hour service within a reasonable driving distance.

• If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy (these prescription drugs include orphan drugs or other specialty pharmaceuticals).

• If you are traveling outside your service area (within the United States) and run out of your medication, if you lose your medication, or if you become ill and cannot get to a network pharmacy.

• If you receive a Part D prescription drug, dispensed by an out‑of‑network institutional‑based pharmacy, while you are in the emergency department, provider‑based clinic, outpatient surgery or other outpatient setting.

• If you have not received your prescription drug during a state or federal disaster declaration or other public health emergency declaration in which you are evacuated or otherwise displaced from your service area or place of residence.

• Out‑of‑network supply is allowed up to a 29‑day supply.• Paper claims should be submitted for reimbursement.

In these cases, please check first with Member Services to see if there is a network pharmacy nearby.


What is the Patient Utilization Management and Safety (PUMS) ProgramSome Members who require additional monitoring may be enrolled in the Patient Utilization Management and Safety (PUMS) program. The PUMS program is required by DMAS and helps make sure your drugs and health services work together in a way that won’t harm your health. As part of this program, we may check the Prescription Monitoring Program (PMP) tool that the Virginia Department of Health Professions maintains to review your drugs. This tool uses an electronic system to monitor the dispensing of controlled substance prescription drugs.

If you are enrolled into PUMS, you may be restricted to or locked into only using one pharmacy or only going to one provider to get certain types of medicines. We will send you a letter to let you know how PUMS works. The lock‑in period is for 12 months. At the end of the lock in period, we’ll check in with you to see if you should continue the program. If you are placed in PUMS and don’t think you should be in the program, you can appeal. You must appeal to us within 60 days of when you get the letter saying that you have been put into PUMS. You can also request a State Fair Hearing. Refer to Appeals, State Fair Hearings, and Complaints in Section 15 of this handbook.

If you’re in the PUMS program, you can get prescriptions after hours if your selected pharmacy doesn’t have 24‑hour access. You’ll also be able to pick a PCP, pharmacy or other provider where you want to be locked in. If you don’t select providers for lock in within 15 days, we’ll choose them for you.

Members who are enrolled in PUMS will receive a letter from Aetna Better Health that provides additional information on PUMS including all of the following information:• A brief explanation of the PUMS program;• A statement explaining the reason for placement in the PUMS program;• Information on how to appeal to Aetna Better Health of Virginia if placed in the

PUMS program; • information regarding how request a State Fair Hearing after first exhausting the

Aetna Better Health’s appeals process; • Information on any special rules to follow for obtaining services, including for

emergency or after hours services; and• Information on how to choose a PUMS provider.

Contact Member Services at the number below or your Care Coordinator if you have any questions on PUMS.


10. How to Access Your CCC Plus Benefits

CCC Plus Benefits As an Aetna Better Health member, you have a variety of health care benefits and services available to you. You will receive most of your services through the Aetna Better Health, but may receive some through DMAS or a DMAS Contractor.• Services provided through Aetna Better Health are described in this Section 10 of

the handbook.• Services covered by DMAS or a DMAS Contractor are described in Section 11 of this

handbook. • Services that are not covered through Aetna Better Health or DMAS are described in

Section 12 of this handbook.

Services you receive through Aetna Better Health or through DMAS will not require you to pay any costs other than your “patient pay” towards long‑term services and supports. Section 13 of this handbook provides information on what a “patient pay” is and how you know if you have one.

General Coverage RulesTo receive coverage for services you must meet the general coverage requirements described below.1. Your services (including medical care, services, supplies, equipment, and drugs)

must be medically necessary. Medically necessary generally means you need the service or supplies to prevent, diagnose, or treat a medical condition or its symptoms based on accepted standards of medical practice.

2. In most cases, you must get your care from a network provider. A network provider is a provider who works with Aetna Better Health. In most cases, Aetna Better Health will not pay for care you get from an out of network provider unless Aetna Better Health authorizes the service. Section 6 has more information about using our network and out‑of‑network providers, including Services You Can Get Without First Getting Approval From Your PCP.

3. Some of your benefits are covered only if your doctor or other network provider gets approval from us first. This is called a service authorization. Section 14 includes more information about service authorizations.

4. If Aetna Better Health is new for you, you can keep seeing the doctors you go to now for the first 90 days. You can also keep getting your authorized services for the duration of the authorization or for 90 days after you first enroll, whichever is sooner. Also, see Continuity of Care Period in Section 3 of this handbook.


Benefits Covered Through Aetna Better HealthAetna Better Health covers all of the following services for you when they are medically necessary. If you have Medicare or another insurance plan, we will coordinate these services with your Medicare or other insurance plan. Refer to Section 11 of this handbook for Services Covered Through the DMAS Medicaid Fee‑For‑Service Program.• Regular medical care, including office visits with your PCP, referrals to specialists,

exams, etc. See Section 6 of this handbook for more information about PCP services.• Preventive care, including regular check‑ups, screenings, and well‑baby/child visits.

See Section 6 of this handbook for more information about PCP services.• Addiction and Recovery Treatment Services (ARTS), including inpatient, outpatient,

community based, medication assisted treatment, peer services, and case management. Services may require authorization. Additional information about ARTS services is provided below in this Section of the handbook.

• Adult day health Care services (see CCC Plus Waiver)• Behavioral health services, including inpatient and outpatient individual, family, and

group psychotherapy services are covered. (Community Mental Health Rehabilitation Services are covered through Magellan, the DMAS Behavioral Health Services Administrator, until December 31, 2017; see Section 11 of this handbook for more information.)

• Care coordination services, including assistance connecting to CCC Plus covered services and to housing, food, and community resources. See Section 4 of this handbook for more information about your Care coordinator.

• Clinic services, including renal dialysis.• CCC Plus Home and Community Based Waiver services, (formerly known as the

EDCD and Technology Assisted Waivers), including: adult day health care, assistive technology, environmental modifications, personal care services, personal emergency response systems (PERS), private duty nursing services, respite services, services facilitation, transition services. Additional information about CCC Plus Waiver services is provided later in this Section. Section 11 of this handbook provides information about DD Waiver Services.

• Colorectal cancer screening.• Court ordered services.• Durable medical equipment (DME) and supplies including medically necessary

respiratory, oxygen, and ventilator equipment and supplies, wheelchairs and accessories, hospital beds, diabetic equipment and supplies, incontinence products, assistive technology, communication devices, and rehabilitative equipment and devices and other necessary equipment and supplies.

• Early and Periodic Screening Diagnostic and Treatment services (EPSDT) for children under age 21. Additional information about EPSDT services is provided later in this Section of the handbook.


• Early Intervention services for children from birth to age 3. Additional information about early intervention services is provided later in this Section of the handbook.

• Electroconvulsive therapy (ECT).• Emergency custody orders (ECO).• Emergency services including emergency transportation services (ambulance, etc.).• Emergency and post stabilization services. Additional information about emergency

and post stabilization services is provided in Section 7 of this handbook. • End stage renal disease services.• Eye examinations.• Family planning services, including services, devices, drugs (including long acting

reversible contraception) and supplies for the delay or prevention of pregnancy. You are free to choose your method for family planning including through providers who are in/out of Aetna Better Health of Virginia’s network. Aetna Better Health of Virginia does not require you to obtain a service authorization or a PCP referral for family planning services.

• Glucose test strips.• Hearing (audiology) services.• Home health services.• Hospice services.• Hospital care – inpatient/outpatient.• Human Immunodeficiency Virus (HIV) testing and treatment counseling.• Immunizations.• Inpatient psychiatric hospital services. • Laboratory, Radiology and Anesthesia Services.• Lead investigations.• Mammograms.• Maternity care includes: pregnancy care, doctors/certified nurse‑midwife services.

Additional information about maternity care is provided in Section 6 of this handbook.

• Nursing facility includes: skilled, specialized care, long stay hospital, and custodial care. Additional information about nursing facility services is provided later in this Section of the handbook.

• Nurse Midwife Services through a Certified Nurse Midwife provider.• Organ transplants.• Orthotics, including braces, splints, and supports ‑ for children under 21, or adults

through an intensive rehabilitation program.• Outpatient hospital services.• Pap smears.• Personal care or personal assistance services (through EPSDT or through the CCC

Plus Waiver).


• Physician’s services or provider services, including doctor’s office visits.• Physical, occupational, and speech therapies.• Podiatry services (foot care).• Prenatal and maternal services.• Prescription drugs. See Section 9 of this handbook for more information on

pharmacy services.• Private duty nursing services (through EPSDT and through the CCC Plus HCBS

Waiver).• Prostate specific antigen (PSA) and digital rectal exams.• Prosthetic devices including arms, legs and their supportive attachments, breasts,

and eye prostheses).• Psychiatric or psychological services.• Radiology services.• Reconstructive breast surgery.• Renal (kidney) dialysis services.• Rehabilitation services – inpatient and outpatient (including physical therapy,

occupational therapy, speech pathology, and audiology services).• Second opinion services from a qualified health care provider within the network

or we will arrange for you to obtain one at no cost outside the network. The doctor providing the second opinion must not be in the same practice as the first doctor. Out of network referrals may be approved when no participating provider is accessible or when no participating provider can meet your individual needs.

• Surgery services when medically necessary and approved by Aetna Better Health.• Telemedicine services.• Temporary detention orders (TDO).• Tobacco Cessation Services for pregnant women, children, and adolescents under

age 21.• Transportation services, including emergency and non‑emergency (air travel, ground

ambulance, stretcher vans, wheelchair vans, public bus, volunteer/ registered drivers, taxicabs). Aetna Better Health will also provide transportation to/from most “carved‑out” and enhanced services. Additional information about transportation services is provided later in this Section of the handbook. Transportation services for DD Waiver services are covered through DMAS, as described in Section 11 of this handbook.

• Vision services. – Well Visits – Call your PCP and set up time for a checkup. – As soon as you get your ID Card, even if you’re not sick, you should set up a time to see your PCP for a checkup. This way, your PCP can get to know you better and help with future health problem before they happen, or at least find them sooner. – Your PCP will look for any problems you might have because of your age, weight, and habits. Your PCP will also help you find ways to be healthier.


– Children should also see their PCP for checkups, shots, and screenings as soon as possible. For checkups, shots and screening, try to call your PCP two or three weeks ahead to ask for an appointment. Keep your appointments. Please do not miss your doctor visits. Your doctor can take better care of you when you’re there for each visit. Give your doctor at least 24‑hours’ notice if you can’t keep your appointment.

• Abortion services‑ coverage is only available in cases where there would be a substantial danger to the life of the mother.

Extra Benefits We Provide That are not Covered by MedicaidValue‑Added Services Additional DetailAs a member of Aetna Better Health, you have access to services that are not generally covered through Medicaid fee‑for‑service. These are known as “enhanced benefits.” Aetna Better Living: enriching members’ lives by providing the following enhanced benefits: Adult dental: Available to members 21 and older (no prior authorization required)

Exam and cleaning twice per year, annual set of bitewing X‑rays, fillings, extractions, root canal or dentures (limited to $525 annually)

Adult vision: Available to members 21 and older (no prior authorization required)

Exam and $100 toward eyewear per year

Adult hearing: Available to members 21 and older (with prior authorization)

Exam and one hearing aid per year, unlimited visits for hearing aid fittings (limited to $500 annually)

Personal care attendant: Available (with prior authorization) to high‑risk members in a nursing facility

24 hours a day and seven days a week

Diabetes care: Available to members 21 and older (with prior authorization)

One pair of therapeutic shoes or two shoe inserts per year (limited to $150 annually)

Medication Adherence Program for Chronic Illness: Available to members with chronic illness (no prior authorization is required)

Assists members with medications and help to ensure they are taking them as prescribed


Value‑Added Services Additional DetailWellness rewards: Available to all members 21 and older (no prior authorization required)

Reloadable incentive card: $15 for diabetic dilated eye exam, $25 for wellness exam (to include HbA1c labs and LCL‑C screening), $15 woman’s mammography, $15 cervical cancer screening, $25 initial colonoscopy, $15 flu shot, and $25 prostate cancer screening

How to Access Early and Periodic Screening, Diagnostic, and Treatment ServicesWhat is EPSDTThe Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program is a federally mandated Medicaid benefit that provides comprehensive and preventive health care services for children under age 21. If you have a child that is under age 21, EPSDT provides appropriate preventive, dental, behavioral health, developmental, and specialty services. It includes coverage for immunizations, well child visits, lead investigations, private duty nursing, personal care, and other services and therapies that treat or make a condition better. It will also cover services that keep your child’s condition from getting worse. EPSDT can provide coverage for medically necessary services even if Medicaid does not normally cover these services.

Getting EPSDT ServicesWe are dedicated to ensuring all Medicaid‑eligible members under the age of 21 receive Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services and that their parents, guardians, and providers are using the resources effectively. Our EPSDT program promotes collaboration with members, providers, State agencies, community organizations, and other stakeholders to achieve this goal for our members.

To help ensure utilization, we facilitate EPSDT well‑child visits for eligible members under the age of 21. To identify health and developmental problems, early and periodic screenings are scheduled in accordance with the Commonwealth through consultation with medical providers involved in the child’s health care.

EPSDT can be particularly important to children who are on the waiting list for the Developmental Disabilities Waiver or the Intellectual Disability Waiver. Receiving services such as skilled nursing or personal care may be needed while the child is waiting for access to the waiver.


Additionally, young adults with disabilities between the ages of 18 and 21 often are eligible for Medicaid when they become eligible for SSI; these young adults may especially benefit from EPSDT. Full EPSDT visits include: • Comprehensive health and developmental history • Comprehensive unclothed physical examination • Appropriate immunizations • Laboratory services such as lead toxicity screening • Dental, vision and hearing screenings • Other screenings as determined to be needed by a provider • Health education and anticipatory guidance as a required component of screening

services

Please call our Member Services Department at 1‑855‑652‑8249 (TTY 1‑800‑828‑1120) to obtain preauthorization for any EPSDT services included but not limited to:• Durable Medical Equipment (DME) • Genetic testing• Home based services including personal care • Imaging (scans) • Injectables • Inpatient services • Neuropsychological testing • Orthotics/Prosthetics • Outpatient surgery • Psychological testing • Services from providers not in your network • Sleep studies • Therapies• Nuclear Radiology• Transplant consultations, evaluations and testing/transplant procedures

Getting Early Intervention ServicesIf you have a baby under the age of three, and you believe that he or she is not learning or developing like other babies and toddlers, your child may qualify for early intervention services. Early intervention includes services such as speech therapy, physical therapy, occupational therapy, service coordination, and developmental services to help families support their child’s learning and development during everyday activities and routines. Services are generally provided in your home.

The first step is meeting with the local Infant and Toddler Connection program in your community to see if your child is eligible. A child from birth to age three is eligible if he or she has (i) a 25% developmental delay in one or more areas of development; (ii)


atypical development; or, (iii) a diagnosed physical or mental condition that has a high probability of resulting in a developmental delay.

For more information, call your Care Coordinator. Your Care Coordinator can help. If your child is enrolled in Aetna Better Health of Virginia, we provide coverage for early intervention services. Your Care Coordinator will work closely with you and the Infant and Toddler Connection program to help you access these services and any other services that your child may need. Information is also available at www.infantva.org or by calling 1‑800‑234‑1448.

How to Access Behavioral Health ServicesBehavioral health services offer a wide range of treatment options for individuals with a mental health or substance use disorder. Many individuals struggle with mental health conditions such as depression, anxiety, or other mental health issues as well as using substances at some time in their lives. These behavioral health services aim to help individuals live in the community and maintain the most independent and satisfying lifestyle possible. Services range from outpatient counseling to hospital care, including day treatment and crisis services. These services can be provided in your home or in the community, for a short or long timeframe, and qualified individuals and organizations perform all necessary services.

Contact your Care Coordinator if you are having trouble coping with thoughts and feelings. Your Care Coordinator will help you make an appointment to speak with a behavioral healthcare professional.

Some Behavioral Health services are covered for you through Magellan, the DMAS Behavioral Health Services Administrator (BHSA). Your Care Coordinator will work closely with the BHSA to coordinate the services you need, including those that are provided through the BHSA.

In order to learn more on how to obtain behavioral health services, please call Member Services at 1‑855‑652‑8249 in order to obtain preauthorization for the following services included but not limited to:• Outpatient services in a psychiatrist’s or licensed clinical psychologist’s private office,

certified hospital outpatient departments, and in the community mental health clinics approved and/or operated by the Virginia Department of Behavioral Health and Developmental Services.

• Medically necessary outpatient individual, family and group mental health and substance abuse treatment services.


• Short‑term inpatient hospital services are covered for members under the age of 21 in participating hospitals when preauthorized by the Aetna Better Health mental health provider. Hospital stays for the treatment of medical conditions that relate to substance abuse (like acute gastritis, seizures, pancreatitis, and cirrhosis) need to be preauthorized by us.

• Psychological tests, when related to an apparent or diagnosed psychiatric illness and as part of your doctor’s plan for deciding what the mental illness or disease is and how to treat it.

• Children who have special needs for medically necessary assessment and treatment services, including children who have been victims of child abuse and neglect, can get this care if: (1) the services are delivered by a doctor or provider whose specialty is in the diagnosis and treatment of child abuse and neglect; (2) the services are provided by a doctor or provider who has similar expertise. A provider who meets these standards will be verified by DMAS.

• Services required by a Temporary Detention Order (TDO) are covered for members up to 96 hours.

• All care given in a free‑standing psychiatric hospital is covered for members up to the age of 21 and over the age of 64. When a child is admitted as a result of an EPSDT screening, a certification of the need for care must be completed as required by federal and state law.

How to Access Addiction and Recovery Treatment Services (ARTS)Aetna Better Health offers a variety of services that help individuals who are struggling with using substances, including drugs and alcohol. Addiction is a medical illness, just like diabetes, that many people deal with and can benefit from treatment no matter how bad the problem may seem. If you need treatment for addiction, we provide coverage for services that can help you. These services include settings in inpatient, outpatient, residential, and community‑based treatment. Medication assisted treatment options are also available if you are dealing with using prescription or non‑prescription drugs. Other options that are helpful include peer services (someone who has experience similar issues and in recovery), as well as case management services. Talk to your PCP or call your Care Coordinator to determine the best option for you and how to get help in addiction and recovery treatment services. To find an ARTS provider, you can look in the Provider and Pharmacy Directory, visit our website, call your Care Coordinator, or contact Member Services at one of the numbers below.


In order to learn more on how to obtain ARTS services, please call Member Services at 1‑855‑652‑8249. Your provider will need to submit the ARTS Service Authorization Review Form for the following services that require prior authorization by Aetna Better Health:• Intensive Outpatient Services• Partial Hospitalization Services• Clinically Managed Low Intensity Residential Services • Clinically Managed Population‑Specific High Intensity Residential Services • Clinical Managed High Intensity Residential Services• Medically Monitored Intensive Inpatient Services • Medically Managed Intensive Inpatient Services

How to Access Long‑Term Services and Supports (LTSS)Aetna Better Health provides coverage for long‑term services and supports (LTSS) including a variety of services and supports that help older individuals and individuals with disabilities meet their daily needs and maintain maximum independence. LTSS can provide assistance that helps you live in your own home or other setting of your choice and improves your quality life. Examples services include personal assistance services (assistance with bathing, dressing, and other basic activities of daily life and self‑care), as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over a long period of time, usually in homes and communities (through a home and community based waiver), but also in nursing facilities. If you need help with these services, please call your Care Coordinator who will help you in the process to find out if you meet the Virginia eligibility requirements for these services. Also, see the Sections: Commonwealth Coordinated Care Plus Waiver, Nursing Facility Services, and How to Get Services if you are in a DD Waiver described later in this Section of the handbook.

Commonwealth Coordinated Care Plus WaiverSome Members may qualify for home and community based care waiver services through the Commonwealth Coordinated Care Plus Waiver (formerly known as the Elderly or Disabled with Consumer Direction and Technology Assistance Waivers).

The Commonwealth Coordinated Care Plus (CCC Plus) Waiver is meant to allow a Member who qualifies for nursing facility level of care to remain in the community with help to meet their daily needs. If determined eligible for CCC Plus Waiver services, you may choose how to receive personal assistance services. You have the option to receive services through an agency (known as agency directed) or you may choose to serve as the employer for a personal assistance attendant (known as self‑directed.) Information on self‑directed care is described in more detail below, in this Section of the handbook.


CCC Plus Waiver Services may include:• Private duty nursing services (agency directed)• Personal care (agency or self‑directed)• Respite care (agency or self‑directed)• Adult day health care• Personal emergency response system (with or without medication monitoring)• Transition coordination/services for Members transitioning to the community from a

nursing facility or long stay hospital• Assistive technology • Environmental modifications

[Individuals enrolled in a DD Waiver should see How to Get Services if you are in a DD Waiver described later in this Section.]

How to Self‑Direct Your CareSelf‑directed care refers to personal care and respite care services provided under the CCC Plus Waiver. These are services in which the Member or their family/caregiver is responsible for hiring, training, supervising, and firing of their attendant. You will receive financial management support in your role as the employer to assist with enrolling your providers, conducting provider background checks, and paying your providers.

If you have been approved to receive CCC Plus Waiver services and would like more information on the self‑directed model of care, please contact your Care Coordinator who will assist you with these services.

Your Care Coordinator will also monitor your care as long as you are receiving CCC Plus Waiver services to make sure the care provided is meeting your daily needs

In order to obtain service authorizations for CCC Plus Waiver services, please call your personal Clinical Care Manager or our Member Service Department 1‑855‑652‑8249 (TTY 1‑800‑828‑1120). The following services require a service authorization but are not limited to:• Home and Community based services including Agency Directed Personal Care,

Consumer directed personal care, Respite Care, Adult Day Health Care, and Personal Emergency Response System (PERS)

Nursing Facility ServicesIf you are determined to meet the coverage criteria for nursing facility care, and choose to receive your long‑term services and supports in a nursing facility, Aetna Better Health will provide coverage for nursing facility care. If you have Medicare, Aetna Better Health will provide coverage for nursing facility care after you exhaust your Medicare covered days in the nursing facility, typically referred to as skilled nursing care.


If you are in a nursing facility, you may be able to move from your nursing facility to your own home and receive home and community based services if you want to. If you are interested in moving out of the nursing facility into the community, talk with your Care Coordinator. Your Care Coordinator is available to work with you, your family, and the discharge planner at the nursing facility if you are interested in moving from the nursing facility to a home or community setting.

If you choose not to leave the nursing facility, you can remain in the nursing facility for as long as you are determined to meet the coverage criteria for nursing facility care.

In order to obtain service authorizations related to nursing facility services, please call your personal Clinical Care Manager or our Member Services at 1‑855‑652‑8249 (TTY 1‑800‑828‑1120). The following service requires a service authorization:• Custodial Care Nursing Facility Admissions

Screening for Long‑term Services and Supports Before you can receive long‑term services and supports (LTSS) you must be screened by a community based or hospital screening team. A screening is used to determine if you meet the level of care criteria for LTSS. Contact your Care Coordinator to find out more about the screening process in order to receive LTSS.

Freedom of ChoiceIf you are approved to receive long‑term services and supports, you have the right to receive care in the setting of your choice:• In your home, or• In another place in the community, or• In a nursing facility.

You can choose the doctors and health professionals for your care from our network. If you prefer to receive services in your home under the CCC Plus Waiver, for example, you can choose to directly hire your own personal care attendant(s), known as self‑directed care. Another option you have is to choose a personal care agency in our network, where the agency will hire, train, and supervise personal assistance workers on your behalf, known as agency direction. You also have the option to receive services in a nursing facility from our network of nursing facility providers.

How to Get Services if You are in a Developmental Disability WaiverIf you are enrolled in one of the DD waivers, you will be enrolled in CCC Plus for your non‑waiver services. The DD waivers include:• The Building Independence (BI) Waiver, • The Community Living (CL) Waiver, and • The Family and Individual Supports (FIS) Waiver.


Aetna Better Health will only provide coverage for your non‑waiver services. Non‑waiver services include all of the services listed in Section 10, Benefits Covered through Aetna Better Health. Exception: If you are enrolled in one of the DD Waivers, you would not also be eligible to receive services through the CCC Plus Waiver.

DD Waiver services, DD and ID targeted case management services, and transportation to/from DD waiver services, will be paid through Medicaid fee‑for‑service as “carved‑out” services. The carve‑out also includes any DD waiver services that are covered through EPSDT for DD waiver enrolled individuals under the age of 21.

If you have a developmental disability and need DD waiver services, you will need to have a diagnostic and functional eligibility assessment completed by your local Community Services Board (CSB). All individuals enrolled in one of the DD waivers follow the same process to qualify for and access BI, CL and FIS services and supports. Services are based on assessed needs and are included in your person‑centered individualized service plan.

The DD waivers have a wait list. Individuals who are on the DD waiver waiting list may qualify to be enrolled in the CCC Plus Waiver until a BI, CL, or FIS DD waiver slot becomes available and is assigned to the individual. The DD waiver waiting list is maintained by the CSBs in your community. For more information on the DD Waivers and the services that are covered under each DD Waiver, visit the Department of Behavioral Health and Developmental Services (DBHDS) website at: http://www.mylifemycommunityvirginia.org/ or call 1‑844‑603‑9248. Your Care Coordinator will work closely with you and your DD or ID case manager to help you get all of your covered services. Contact your Care Coordinator if you have any questions or concerns.

How to Get Non‑Emergency Transportation ServicesNon‑Emergency Transportation Services Covered by Aetna Better HealthNon‑Emergency transportation services are covered by Aetna Better Health for covered services, carved out services, and enhanced benefits. Exception: If you are enrolled in a DD Waiver, Aetna Better Health provides coverage for your transportation to/from your non‑waiver services. (Refer to Transportation to/from DD Waiver Services below.)

Transportation may be provided if you have no other means of transportation and need to go to a physician or a health care facility for a covered service. For urgent or non‑emergency medical appointments, call the transportation line at 1‑855‑652‑8249. If you are having problems getting transportation to your appointments, call Member Services at 1‑855‑652‑8249. Member services is here to help.


In case of a life‑threatening emergency, call 911. Refer to How to Get Care for Emergencies in Chapter 7 of this handbook.

Transportation to medical appointments is a covered benefit, you must call 3 working days before your visit or we will not be able to guarantee a ride. We must preauthorize the service. You can ask for medical transportation to get your eye, dental, behavioral health, and medical visits. Transportation is not covered for picking up prescriptions and refills at a pharmacy when drugs can be delivered or mailed. Transportation is covered if your pharmacy doesn’t have delivery or will not mail the prescription or the prescription cannot be filled at the medical facility. Normally the prescription should be filled initially on the return trip from the medical appointment. Transportation may be in the form of a public or private vehicle. This transportation must be used only when your visit is for care that is covered and you do not have your own transportation. Please also refer back to the enhanced benefits on page 62 for an additional transportation option.

Transportation to and From DD Waiver ServicesIf you are enrolled in a DD Waiver, Aetna Better Health provides coverage for your transportation to and from your non‑waiver services. (Call the number above for transportation to your non‑waiver services.)

Transportation to your DD Waiver services is covered by the DMAS Transportation Contractor. You can find out more about how to access transportation services through the DMAS Transportation Contractor on the website at: http://www.dmas.virginia.gov/Content_pgs/trn‑info.aspx or by calling the Transportation Contractor. Transportation for routine appointments is taken Monday through Friday between the hours of 6:00 AM to 8:00 PM. The DMAS Transportation Contractor is available 24 hours a day, 7 days a week to schedule urgent reservations, at: 1‑866‑386‑8331 or TTY 1‑866‑288‑3133 or 711 to reach a relay operator.

If you have problems getting transportation to your DD waiver services, you may call your DD or ID Waiver case manager or the DMAS Transportation Contractor at the number above. You can also call your Care Coordinator. Your Care Coordinator will work closely with you and your DD or ID Waiver case manager to help get the services that you need. Member Services is also available to help at the number below.


11. Services Covered Through the DMAS Medicaid Fee‑For‑Service Program

Carved‑Out ServicesThe Department of Medical Assistance Services will provide you with coverage for the services listed below. These services are known as “carved‑out services.” Your provider bills fee‑for‑service Medicaid (or a DMAS Contractor) for these services.

Your Care Coordinator can also help you to access these services if you need them. • Community Mental Health Rehabilitation Services (CMHRS) are currently provided

through Magellan, the DMAS Behavioral Health Services Administrator. Beginning on and after January 1, 2018, Aetna Better Health will provide coverage for CMHRS. We will send you additional information at least 30 days before this change becomes effective.

• CMHRS are listed below. Detailed information about CMHRS is available on the Magellan website at: http://www.magellanofvirginia.com or by calling: 1‑800‑424‑4046 TDD: 1‑800‑424‑4048 or TTY: 711. You can also call your Care Coordinator for assistance. – Mental Health Case Management – Therapeutic Day Treatment (TDT) for Children – Day Treatment/ Partial Hospitalization for Adults – Crisis Intervention and Stabilization – Intensive Community Treatment – Mental Health Skill‑building Services (MHSS) – Intensive In‑Home – Psychosocial Rehab – Level A and B Group Home – Treatment Foster Care Case Management – Behavioral Therapy – Mental Health Peer Supports

• Dental Services are provided through the Smiles For Children program. DMAS has contracted with DentaQuest to coordinate the delivery of all Medicaid dental services. The name of the program is Smiles For Children. Smiles for Children provides coverage for the following populations and services: – For children under age 21: diagnostic, preventive, restorative/surgical procedures, as well as orthodontia services. – For pregnant women: x‑rays and examinations, cleanings, fillings, root canals, gum related treatment, crowns, bridges, partials, and dentures, tooth extractions and other oral surgeries, and other appropriate general services. Orthodontic treatment is not included. The dental coverage ends 60 days after the baby is born.


– For adults age 21 and over, Smiles For Children coverage is only available for limited medically necessary oral surgery services. Routine dental services are not covered for adults other than as described above for pregnant women.

If you have any questions about your dental coverage through Smiles for Children, you can reach DentaQuest Member Services at 1‑888‑912‑3456, Monday through Friday, 8:00 AM ‑ 6:00 PM EST. The TTY/TDD number is 1‑800‑466‑ 7566. Additional information is provided at: http://www.dmas.virginia.gov/Content_pgs/dnt‑enrollees.aspx.

Aetna Better Health provides coverage for non‑emergency transportation for any covered dental services, as described above. Contact Member Services at the number below if you need assistance. • Adult dental: Available to members 21 and older (no prior authorization required)—

exam and cleaning twice per year, annual set of bitewing X‑rays, fillings, extractions, root canal or dentures (limited to $525 annually)

• Developmental Disability (DD) Waiver Services, including Case Management for DD Waiver Services, are covered through DBHDS. The carve‑out includes any DD Waiver services that are covered through EPSDT for DD waiver enrolled individuals and transportation to/from DD Waiver services. Also, see How to Get Services if you are in a Developmental Disability Waiver in Section 10 of this handbook.

• School health services including certain medical, mental health, hearing, or rehabilitation therapy services that are arranged by your child’s school. The law requires schools to provide students with disabilities a free and appropriate public education, including special education and related services according to each student’s Individualized Education Program (IEP). While schools are financially responsible for educational services, in the case of a Medicaid‑eligible student, part of the costs of the services identified in the student’s IEP may be covered by Medicaid. When covered by Medicaid, school health services are paid by DMAS. Contact your child’s school administrator if you have questions about school health services.

Services That Will End Your CCC Plus EnrollmentIf you receive any of the services below, your enrollment with Aetna Better Health will end. You will receive these services through DMAS or a DMAS Contractor. • PACE (Program of All Inclusive Care for the Elderly). For more information about

PACE, talk to your Care Coordinator or visit: http://www.dmas.virginia.gov/Content_pgs/ltc‑pace.aspx.

• Medicaid Money Follows the Person (MFP) Program. For more information about MFP, talk to your Care Coordinator or visit: http://www.dmas.virginia.gov/Content_pgs/ltc‑mfp.aspx.


• Alzheimer’s Assisted Living Waiver. For more information about the Alzheimer’s waiver, talk to your Care Coordinator or visit: http://www.dmas.virginia.gov/Content_pgs/ltc‑wvr_aal.aspx.

• You reside in an Intermediate Care Facility for Individuals with Intellectual and Developmental Disabilities (ICF/IID).

• You are receiving care in a Psychiatric Residential Treatment Level C Facility (children under 21).

• You reside in a Veteran’s Nursing Facility.• You reside in one of these State long‑term care facilities: Piedmont, Catawba, Hiram

Davis, or Hancock.

12. Services Not Covered by CCC Plus

The following services are not covered by Medicaid or Aetna Better Health. If you receive any of the following non‑covered services, you will be responsible for the cost of these services. • Acupuncture• Administrative expenses, such as completion of forms and copying records• Artificial insemination, in‑vitro fertilization, or other services to promote fertility• Certain drugs not proven effective• Certain experimental surgical and diagnostic procedures• Chiropractic services • Cosmetic treatment or surgery• Daycare, including companion services for the elderly (except in some home‑ and

community‑based service waivers)• Drugs prescribed to treat hair loss or to bleach skin• Immunizations if you are age 21 or older (except for flu and pneumonia for those at

risk and as authorized by Aetna Better Health)• Medical care other than emergency services, urgent services, , or family planning

services, received from providers outside of the network unless authorized by Aetna Better Health

• Personal care services (except through some home and community‑based service waivers or under EPSDT)

• Prescription drugs covered under Medicare Part D, including the Medicare copayment.

• Private duty nursing (except through some home and community‑based service waivers or under EPSDT)

• Weight loss clinic programs unless authorized• Care outside of the United States


If You Receive Non‑Covered ServicesWe cover your services when you are enrolled with our plan and:• Services are medically necessary, and• Services are listed as Benefits Covered Through Aetna Better Health in Section 10 of

this handbook, and• You receive services by following plan rules.

If you get services that aren’t covered by our plan or covered through DMAS, you must pay the full cost yourself. If you are not sure and want to know if we will pay for any medical service or care, you have the right to ask us. You can call Member services or your Care Coordinator to find out more about services and how to obtain them. You also have the right to ask for this in writing. If we say we will not pay for your services, you have the right to appeal our decision.

Section 15 provides instructions for how to appeal Aetna Better Health’s coverage decisions. You may also call Member Services to learn more about your appeal rights or to obtain assistance in filing an appeal.

13. Member Cost Sharing

There are no copayments for services covered through the CCC Plus Program. This includes services that are covered through Aetna Better Health or services that are carved‑out of the CCC Plus contract. The services provided through Aetna Better Health or through DMAS will not require you to pay any costs other than your patient pay towards long‑term services and supports. See the Member Patient Pay Section below.

CCC Plus does not allow providers to charge you for covered services. Aetna Better Health pays providers directly, and we protect you from any charges. This is true even if we pay the provider less than the provider charges for a service. If you receive a bill for a covered service, contact Member services and they will help you.

If you get services that aren’t covered by our plan or covered through DMAS, you must pay the full cost yourself. If you are not sure and want to know if we will pay for any medical service or care, you have the right to ask us. You can call Member services or your Care Coordinator to find out more about services and how to obtain them. You also have the right to ask for this in writing. If we say we will not pay for your services, you have the right to appeal our decision. See Section 12 of this handbook for a list of non‑covered services.


Member Patient Pay Towards Long‑term Services and SupportsYou may have a patient pay responsibility towards the cost of nursing facility care and home and community based waiver services. A patient pay is required to be calculated for all Members who get nursing facility or home and community based waiver services. When your income exceeds a certain amount, you must contribute toward the cost of your long‑term services and supports. If you have a patient pay amount, you will receive notice from your local Department of Social Services (DSS) of your patient pay responsibility. DMAS also shares your patient pay amount with Aetna Better Health if you are required to pay towards the cost of your long‑term services and supports. If you have questions about your patient pay amount, contact your Medicaid eligibility worker at the local Department of Social Services.

Medicare Members and Part D DrugsIf you have Medicare, you get your prescription medicines from Medicare Part D, not from the CCC Plus Medicaid program. CCC Plus does not pay the copayment for the medicines that Medicare Part D covers.

14. Service Authorization and Benefit Determination

Service AuthorizationThere are some treatments, services, and drugs that you need to get approval for before you receive them or in order to be able to continue receiving them. This is called a service authorization. You, your doctor, or someone you trust can ask for a service authorization.

If the services you require are covered through Medicare then a service authorization from Aetna Better Health is not required. If you have questions regarding what services are covered under Medicare, please contact your Medicare health plan. You can also contact your Aetna Better Health Care Coordinator.

A service authorization helps to determine if certain services or procedures are medically needed and covered by the plan. Decisions are based on what is right for each member and on the type of care and services that are needed. • We look at standards of care based on:• Medical policies• National clinical guidelines• Medicaid guidelines • Your health benefits


Aetna Better Health does not reward employees, consultants, or other providers to:• Deny care or services that you need• Support decisions that approve less than what you need• Say you don’t have coverage

Service authorizations are not required for early intervention services, emergency care, family planning services (including long acting reversible contraceptives), preventive services, and basic prenatal care.

The following treatments and services must be authorized before you get them: • Durable Medical Equipment (DME) • Genetic testing• Home based services including personal care • Imaging (scans) • Injectables • Inpatient services • Neuropsychological testing • Orthotics/Prosthetics • Outpatient surgery • Psychological testing • Services from providers not in your network • Sleep studies • Therapies• Nuclear Radiology• Transplant consultations, evaluations and testing/transplant procedures

To find out more about how to request approval for these treatments or services you can contact Member Services at the number below or call your Care Coordinator.

Service Authorizations and Continuity of CareIf you are new to Aetna Better Health we will honor any service authorization approvals made by DMAS or issued by another CCC Plus plan for up to 90 days (or until the authorization ends if that is sooner than 90 days).

How to Submit a Service Authorization Request Some services may need to be approved as “medically necessary” by Aetna Better Health before your provider can arrange for you to get these services. This process is called “prior authorization.” Your provider or care coordinator will work Aetna Better Health Utilization Management team to request and secure prior authorization for any of these services. Your provider needs to call us for approval at least 3 working days before the scheduled care. We may ask to see written notes showing that your care was medically needed before it is preauthorized.


Prior Authorization Process:1. Your health care provider must contact Aetna Better Health with information that

can support your covered service and medical necessity for service.2. An Aetna Better Health licensed clinician will review the services requested. We

will decide if your request can be approved based on Aetna Better Health’s clinical guidelines. If your clinician can’t approve it, an Aetna Better health doctor will review it. Our doctor may attempt to contact your requesting provider to discuss the request.

3. If your authorization is approved, we will notify your provider that it’s approved.4. If a denial, reduction, suspension, or termination of services happens, we will send

you a “Notice of Adverse Benefit Determination” letter. Your health care provider will also be notified of the decision.

5. If you do not agree with our decision, you have the right to file an appeal and ask us to look at your case again. (See Your Right to Appeal, page 82)

6. At any time, you and your provider may ask for a copy of the clinical criteria that was used to make a denial decision for medical services.

What Happens After We Get Your Service Authorization RequestAetna Better Health has a review team to be sure you receive medically necessary services. Doctors and nurses are on the review team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards. The standards we use to determine what is medically necessary are not allowed to be more restrictive than those that are used by DMAS.

Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination (decision). These decisions will be made by a qualified health care professional. If we decide that the requested service is not medically necessary, the decision will be made by a medical or behavioral health professional, who may be a doctor or other health care professional who typically provides the care you requested. You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity.

After we get your request, we will review it under a standard or expedited (fast) review process. You or your doctor can ask for an expedited review if you believe that a delay will cause serious harm to your health. If your request for an expedited review is denied, we will tell you and your case will be handled under the standard review process.


Timeframes for Service Authorization ReviewIn all cases, we will review your request as quickly as your medical condition requires us to do so but no later than mentioned below.

Physical Health Services Service Authorization Review TimeframesInpatient Hospital Services(Standard or Expedited Review Process)

Within 1 business day if we have all the information we need, or up to 3 business days if we need additional information, or as quickly as your condition requires.

Outpatient Services(Standard Review Process)

Within 3 business days if we have all the information we need, or up to 5 business days if we need additional information.

Outpatient Services(Expedited Review Process)

Within 72 hours from receipt of your request or as quickly as your condition requires.

Long‑term Services and SupportsSame as those listed above(Expedited Review Process)

Within 72 hours from receipt of your request or as quickly as your condition requires.

Long‑term Services and Supports• Includes CCC Plus Waiver services • EPSDT Personal Care and Private

Duty Nursing• Nursing Facility• Long Stay Hospital• Hospice (Standard Review Process)

Within 5 business days from receipt of your request.

Also see Screening for Long‑term Services and Supports in Section 10 of this handbook.

Behavioral Health Services Service Authorization Review TimeframesOutpatient(Standard Review Process)

Within 3 business days if we have all of the information we need, or up to 5 business days if we need additional information, or as quickly as your condition requires.

Inpatient(Standard Review)

Within 1 business day if we have all of the information we need, or up to 3 business days if we need additional information, or as quickly as your condition requires.

Inpatient(Expedited Review)

Within 3 hours.

Other Urgent Services Within 24 hours or as quickly as your condition requires.


Pharmacy Services Service Authorization Review TimeframesPharmacy services We must provide decisions by telephone or other

telecommunication device within 24 hours.There may be an instance where your medication requires a service authorization, and your prescribing physician cannot readily provide authorization information to us, for example over the weekend or on a holiday. If your pharmacist believes that your health would be compromised without the benefit of the drug, we may authorize a 72‑hour emergency supply of the prescribed medication. This process provides you with a short‑term supply of the medications you need and gives time for your physician to submit an authorization request for the prescribed medication.

If we need more information to make either a standard or expedited decision about your service request we will:• Write and tell you and your provider what information is needed. If your request is in

an expedited review, we will call you or your provider right away and send a written notice later.

• Tell you why the delay is in your best interest.• Make a decision no later than 14 days from the day we asked for more information.

You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give Aetna Better Health to help decide your case. This can be done by calling Member Services at the number below or mailing the information to Aetna Better Health of Virginia, Attn: Appeals, 9881 Mayland Drive, Richmond, VA 23233.

You or someone you trust can file a complaint with Aetna Better Health if you don’t agree with our decision to take more time to review your request. You or someone you trust can also file a complaint about the way Aetna Better Health handled your service authorization request to the State through the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608. Also, see Your Right to File a Complaint, in Section 15 of this handbook.


Benefit DeterminationWe will notify you with our decision by the date our time for review has expired. However, if for some reason you do not hear from us by that date, it is the same as if we denied your service authorization request. If you disagree with our decision, you have the right to file an appeal with us. Also, see Your Right to Appeal, in Section 15 in this handbook.

We will tell you and your provider in writing if your request is denied. A denial includes when the request is approved for an amount that is less than the amount requested. We will also tell you the reason for the decision and the contact name, address, and telephone number of the person responsible for making the adverse determination. We will explain what options for appeals you have if you do not agree with our decision. Also, see Your Right to Appeal, in Section 15 of this handbook.

Advance NoticeIn most cases, if we make a benefit determination to reduce, suspend, or end a service we have already approved and that you are now getting, we must tell you at least 10 days before we make any changes to the service. Also, see Continuation of Benefits in Section 15 of this handbook.

Post Payment ReviewIf we are checking on care or services that you received in the past, we perform a provider post payment review. If we deny payment to a provider for a service, we will send a notice to you and your provider the day the payment is denied. You will not have to pay for any care you received that was covered by Aetna Better Health even if we later deny payment to the provider.

15. Appeals, State Fair Hearings, and Complaints (Grievances)

Your Right to AppealYou have the right to appeal any adverse benefit determination (decision) by Aetna Better Health that you disagree with that relates to coverage or payment of services.

For example, you can appeal if Aetna Better Health denies:• A request for a health care service, supply, item or drug that you think you should be

able to get, or• A request for payment of a health care service, supply, item, or drug that Aetna

Better Health denied.

You can also appeal if Aetna Better Health stops providing or paying for all or a part of a service or drug you receive through CCC Plus that you think you still need.


Authorized RepresentativeYou may wish to authorize someone you trust to appeal on your behalf. This person is known as your authorized representative. You must inform Aetna Better Health of the name of your authorized representative. You can do this by calling our Member Services Department at one of the phone numbers below. We will provide you with a form that you can fill out and sign stating who your representative will be.

Adverse Benefit DeterminationThere are some treatments and services that you need to get approval for before you receive them or in order to be able to continue receiving them. Asking for approval of a treatment or service is called a service authorization request. This process is described earlier in this handbook. Any decision we make to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination. Refer to Service Authorization and Benefit Determinations in Section 14 of this handbook.

How to Submit Your AppealIf you are not satisfied with a decision we made about your service authorization request, you have 60 calendar days after hearing from us to file an appeal. You can do this yourself or ask someone you trust to file the appeal for you. You can call Member Services at one of the numbers below if you need help filing an appeal or if you need assistance in another language or require an alternate format. We will not treat you unfairly because you file an appeal.

You can file your appeal by phone or in writing. You can send the appeal as a standard appeal or an expedited (fast) appeal request.

You or your doctor can ask to have your appeal reviewed under the expedited process if you believe your health condition or your need for the service requires an expedited review. Your doctor will have to explain how a delay will cause harm to your physical or behavioral health. If your request for an expedited appeal is denied we will tell you and your appeal will be reviewed under the standard process.

Send your Appeal request to:

Aetna Better Health of VirginiaAttn: Appeals9881 Mayland DriveRichmond, VA 23233 Fax number 1‑866‑669‑2459Phone number 1‑855‑652‑8249


If you send your standard appeal by phone, it must be followed up in writing. Expedited process appeals submitted by phone do not require you to submit a written request.

Continuation of BenefitsIn some cases, you may be able to continue receiving services that were denied by us while you wait for your appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for an appeal:

Within ten days from being told that your request is denied or care is changing; or

By the date the change in services is scheduled to occur.If your appeal results in another denial, you may have to pay for the cost of any continued benefits that you received if the services were provided solely because of the requirements described in this Section.

What Happens After We Get Your AppealWithin three (3) days, we will send you a letter to let you know we have received and are working on your appeal.

Appeals of clinical matters will be decided by qualified health care professionals who did not make the first decision and who have appropriate clinical expertise in treatment of your condition or disease.

Before and during the appeal, you or your authorized representative can see your case file, including medical records and any other documents and records being used to make a decision on your case. This information is available at no cost to you.

You can also provide information that you want to be used in making the appeal decision in person or in writing. Mail information to:

Aetna Better Health of VirginiaAttn: Appeals9881 Mayland DriveRichmond, VA 23233 Fax 1‑866‑669‑2459

You can also call Member Services at one of the numbers below if you are not sure what information to give us.

Timeframes for AppealsStandard AppealsIf we have all the information we need we will tell you our decision within 30 days of when we receive your appeal request. We will tell you within 2 calendar days after receiving your appeal if we need more information. A written notice of our decision will be sent within 2 calendar days from when we make the decision.


Expedited AppealsIf we have all the information we need, expedited appeal decisions will be made within 72 hours receipt of your appeal. We will tell you within 2 calendar days after receiving your appeal if we need more information. We will tell you our decision by phone and send a written notice within 2 calendar days from when we make the decision.

If We Need More InformationIf we can’t make the decision within the needed timeframes because we need more information, we will:• Write you and tell you what information is needed. If your request is in an expedited

review, we will call you right away and send a written notice later;• Tell you why the delay is in your best interest; and• Make a decision no later than 14 additional days from the timeframes described

above.

You, your provider, or someone you trust may also ask us to take more time to make a decision. This may be because you have more information to give Aetna Better Health to help decide your case. This can be done by calling or writing to:

Aetna Better Health of VirginiaAttn: Appeals9881 Mayland DriveRichmond, VA 23233Fax 1‑866‑669‑2459Phone 1‑855‑652‑8249

You or someone you trust can file a complaint with Aetna Better Health if you do not agree with our decision to take more time to review your appeal. You or someone you trust can also file a complaint about the way Aetna Better Health handled your appeal to the State through the CCC Plus Help Line at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608.

If we do not tell you our decision about your appeal on time, you have the right to appeal to the State through the State Fair Hearing process. An untimely response by us is considered a valid reason for you to appeal further through the State Fair Hearing process.

Written Notice of Appeal DecisionWe will tell you and your provider in writing if your request is denied or approved in an amount less than requested. We will also tell you the reason for the decision and the contact name, address, and telephone number of the person responsible for making the adverse determination. We will explain your right to appeal through the State Fair Hearing Process if you do not agree with our decision.


Your Right to a State Fair HearingIf you disagree with our decision on your appeal request, you can appeal directly to DMAS. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request for services within the times described in this handbook. The State requires that you first exhaust (complete) Aetna Better Health appeals process before you can file an appeal request through the State Fair Hearing process. If we do not respond to your appeal request timely, DMAS will count this as an exhausted appeal.

Standard or Expedited Review RequestsFor standard requests, appeals will be heard and DMAS will give you an answer generally within 90 days from the date you filed your appeal. If you want your State Fair Hearing to be handled quickly, you must write “EXPEDITED REQUEST” on your appeal request. You must also ask your doctor to send a letter to DMAS that explains why you need an expedited appeal. DMAS will tell you if you qualify for an expedited appeal within 72 hours of receiving the letter from your doctor.

Authorized RepresentativeYou can give someone like your PCP, provider, or friend or family member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative.

Where to Send the State Fair Hearing RequestYou or your representative must send your standard or expedited appeal request to DMAS by internet, mail, fax, email, telephone, in person, or through other commonly available electronic means. Send State Fair Hearing requests to DMAS within no more than 120 calendar days from the date of our final decision. You may be able to appeal after the 120 day deadline in special circumstances with permission from DMAS.

You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the DMAS website at http://www.dmas.virginia.gov/Content_pgs/appeal‑home.aspx. You should also send DMAS a copy of the letter we sent to you in response to your Appeal.

You must sign the appeal request and send it to:

Appeals DivisionDepartment of Medical Assistance Services600 E. Broad StreetRichmond, Virginia 23219Fax: 1‑804‑452‑5454

Standard and Expedited Appeals may also be made by calling 1‑804‑371‑8488.


After You File Your State Fair Hearing AppealDMAS will notify you of the date, time, and location of the scheduled hearing. Most hearings can be done by telephone.

State Fair Hearing Timeframes Expedited Appeal

If you qualify for an expedited appeal, DMAS will give you an answer to your appeal within 72 hours of receiving the letter from your doctor. If DMAS decides right away that you win your appeal, they will send you their decision within 72 hours of receiving the letter from your doctor. If DMAS does not decide right away, you will have an opportunity to participate in a hearing to present your position. Hearings for expedited decisions are usually held within one or two days of DMAS receiving the letter from your doctor. DMAS still has to give you an answer within 72 hours of receiving your doctor’s letter.

Standard AppealIf your request is not an expedited appeal, or if DMAS decides that you do not qualify for an expedited appeal, DMAS will generally give you an answer within 90 days from the date you filed your appeal. You will have an opportunity to participate in a hearing to present your position before a decision is made.

Continuation of BenefitsIn some cases, you may be able to continue receiving services that were denied by us while you wait for your State Fair Hearing appeal to be decided. You may be able to continue the services that are scheduled to end or be reduced if you ask for an appeal:• Within ten days from being told that your request is denied or care is changing; • By the date the change in services is scheduled to occur.

Your services will continue until you withdraw the appeal, the original authorization period for your service ends, or the State Fair Hearing Officer issues a decision that is not in your favor. However, you may have to repay Aetna Better Health for any services you receive during the continued coverage period if Aetna Better Health’s adverse benefit determination is upheld and the services were provided solely because of the requirements described in this Section.

If the State Fair Hearing Reverses the DenialIf services were not continued while the State Fair Hearing was pendingIf the State Fair Hearing decision is to reverse the denial, Aetna Better Health must authorize or provide the services under appeal as quickly as your condition requires and no later than 72 hours from the date Aetna Better Health receives notice from the State reversing the denial.


If services were provided while the State Fair Hearing was pendingIf the State Fair hearing decision is to reverse the denial and services were provided while the appeal is pending, Aetna Better Health must pay for those services, in accordance with State policy and regulations.

If You Disagree with the State Fair Hearing DecisionThe State Fair Hearing decision is the final administrative decision rendered by the Department of Medical Assistance Services. If you disagree with the Hearing Officer’s decision, you may appeal it to your local circuit court.

Your Right to File a Complaint (Grievance)Aetna Better Health will try its best to deal with your concerns as quickly as possible to your satisfaction. Depending on what type of concern you have, it will be handled as a complaint (also known as a grievance) or as an appeal.

Timeframe for ComplaintsYou can file a complaint with us at any time.

What Kinds of Problems Should be ComplaintsThe complaint process is used for concerns related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the Aetna Better Health’s complaint process.

Complaints about quality• You are unhappy with the quality of care, such as the care you got in the hospital.

Complaints about privacy• You think that someone did not respect your right to privacy or shared information

about you that is confidential or private.

Complaints about poor customer service• A health care provider or staff was rude or disrespectful to you.• Aetna Better Health staff treated you poorly.• Aetna Better Health is not responding to your questions.• You are not happy with the assistance you are getting from your Care Coordinator.

Complaints about accessibility• You cannot physically access the health care services and facilities in a doctor or

provider’s office.• You were not provided requested reasonable accommodations that you needed in

order to participate meaningfully in your care.


Complaints about communication access• Your doctor or provider does not provide you with a qualified interpreter for

the deaf or hard of hearing or an interpreter for another language during your appointment.

Complaints about waiting times• You are having trouble getting an appointment, or waiting too long to get it.• You have been kept waiting too long by doctors, pharmacists, or other health

professionals or by Member Services or other Aetna Better Health staff.

Complaints about cleanliness• You think the clinic, hospital or doctor’s office is not clean.

Complaints about communications from us• You think we failed to give you a notice or letter that you should have received.• You think the written information we sent you is too difficult to understand.• You asked for help in understanding information and did not receive it.

There Are Different Types of ComplaintsYou can make an internal complaint and/or an external complaint. An internal complaint is filed with and reviewed by Aetna Better Health. An external complaint is filed with and reviewed by an organization that is not affiliated with Aetna Better Health.

Internal ComplaintsTo make an internal complaint, call Member Services at the number below. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can file a complaint in writing, by mailing or faxing it to us at:

Aetna Better Health of VirginiaAttn: Grievances9881 Mayland DriveRichmond, VA 23233Fax 1‑866‑669‑2459

So that we can best help you, include details on who or what the complaint is about and any information about your complaint. Aetna Better Health will review your complaint and request any additional information. You can call Member Services at the number below if you need help filing a complaint or if you need assistance in another language or format.

We will notify you of the outcome of your complaint within a reasonable time, but no later than 30 calendar days after we receive your complaint.


If your complaint is related to your request for an expedited appeal, we will respond within 24 hours after the receipt of the complaint.

External ComplaintsYou Can File a Complaint with the CCC Plus HelplineYou can make a complaint about Aetna Better Health to the CCC Plus Helpline. Contact the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608.

You Can File a Complaint with the Office for Civil RightsYou can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. You can also visit http://www.hhs.gov/ocr for more information.

You may contact the local Office for Civil Rights office at:

Office of Civil Rights‑ Region IIIDepartment of Health and Human Services150 S Independence Mall West Suite 372 Public Ledger BuildingPhiladelphia, PA 191061‑800‑368‑1019Fax: 215‑861‑4431TDD: 1‑800‑537‑7697

You Can File a Complaint with the Office of the State Long‑Term Care Ombudsman

The State Long‑Term Care Ombudsman serves as an advocate for older persons receiving long‑term care services. Local Ombudsmen provide older Virginians and their families with information, advocacy, complaint counseling, and assistance in resolving care problems.

The State’s Long‑Term Care Ombudsman program offers assistance to persons receiving long‑term care services, whether the care is provided in a nursing facility or assisted living facility, or through community‑based services to assist persons still living at home. A Long‑Term Care Ombudsman does not work for the facility, the State, or Aetna Better Health. This helps them to be fair and objective in resolving problems and concerns.

The program also represents the interests of long‑term care consumers before state and federal government agencies and the General Assembly.


The State Long‑Term Care Ombudsman can help you if you are having a problem with Aetna Better Health or a nursing facility. The State Long‑Term Care Ombudsman is not connected with us or with any insurance company or health plan. The services are free.

Office of the State Long‑Term Care Ombudsman1‑800‑552‑5019 This call is free.1‑800‑464‑9950

This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.

Virginia Office of the State Long‑Term Care OmbudsmanVirginia Department for Aging and Rehabilitative Services8004 Franklin Farms DriveHenrico, Virginia 23229804‑662‑9140http://www.ElderRightsVA.org

16. Member Rights

Your RightsIt is the policy of Aetna Better Health to treat you with respect. We also care about keeping a high level of confidentiality with respect for your dignity and privacy. As a CCC Plus Member, you have certain rights. You have the right to:• Receive timely access to care and services;• Take part in decisions about your health care, including your right to choose your

providers from Aetna Better Health network providers and your right to refuse treatment;

• Choose to receive long‑term services and supports in your home or community or in a nursing facility;

• Confidentiality and privacy about your medical records and when you get treatment;• Receive information and to discuss available treatment options and alternatives

presented in a manner and language you understand;• Get information in a language you understand ‑ you can get oral translation services

free of charge;• Receive reasonable accommodations to ensure you can effectively access

and communicate with providers, including auxiliary aids, interpreters, flexible scheduling, and physically accessible buildings and services;

• Receive information necessary for you to give informed consent before the start of treatment;

• Be treated with respect and dignity;


• Get a copy of your medical records and ask that the records be amended or corrected;

• Participate in decisions regarding your healthcare, including the right to refuse treatment;

• Be free from restraint or seclusion unless ordered by a physician when there is an imminent risk of bodily harm to you or others, or when there is a specific medical necessity. Seclusion and restraint will never be used a s a means of coercion, discipline, retaliation, or convenience;

• Get care in a culturally competent manner including without regard to disability, gender, race, health status, color, age, national origin, sexual orientation, marital status or religion;

• Be informed of where, when and how to obtain the services you need from Aetna Better Health, including how you can receive benefits from out‑of‑network providers if the services are not available in Aetna Better Health’s network.

• Complain about Aetna Better Health to the State. You can call the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608 to make a complaint about us.

• Appoint someone to speak for you about your care and treatment and to represent you in an Appeal;

• Make advance directives and plans about your care in the instance that you are not able to make your own health care decisions. See Section 17 of this handbook for information about Advance Directives.

• Change your CCC Plus health plan once a year for any reason during open enrollment or change your MCO after open enrollment for an approved reason. Reference Section 2 of this handbook or call the CCC Plus Helpline at 1‑844‑374‑9159 or TDD 1‑800‑817‑6608 or visit the website at cccplusva.com for more information.

• Appeal any adverse benefit determination (decision) by Aetna Better Health that you disagree with that relates to coverage or payment of services. See Your Right to Appeal in this Section 15 of the handbook.

• File a complaint about any concerns you have with our customer service, the services you have received, or the care and treatment you have received from one of our network providers. See Your Right to File a Complaint in Section 15 of this handbook.

• To receive information from us about our plan, your covered services, providers in our network, and about your rights and responsibilities.

• To make recommendations regarding our member rights and responsibility policy, for example by joining our Member Advisory Committee (as described later in this Section of the handbook.)


Your Right to be SafeEveryone has the right to live a safe life in the home or setting of their choice. Each year, many older adults and younger adults who are disabled are victims of mistreatment by family members, by caregivers and by others responsible for their well‑being. If you, or someone you know, is being abused, physically, is being neglected, or is being taken advantage of financially by a family member or someone else, you should call your local department of social services or the Virginia Department of Social Services’ 24‑hour, toll‑free hotline at: 1‑888 832‑3858. You can make this call anonymously; you do not have to provide your name. The call is free.

They can also provide a trained local worker who can assist you and help you get the types of services you need to assure that you are safe.

Your Right to Confidentiality Aetna Better Health will only release information if it is specifically permitted by state and federal law or if it is required for use by programs that review medical records to monitor quality of care or to combat fraud or abuse.

Aetna Better Health staff will ask questions to confirm your identity before we discuss or provide any information regarding your health information.

We understand the importance of keeping your personal and health information secure and private. Both Aetna Better Health and your doctors make sure that all your member records are kept safe and private. We limit access to your personal information to those who need it. We maintain safeguards to protect it. For example, we protect access to our buildings and computer systems. Our Privacy Office also assures the training of our staff on our privacy and security policies. If needed, we may use and share your personal information for “treatment,” “payment,” and “health care operations.” We limit the amount of information that we share about you as required by law. For example, HIV/AIDS, substance abuse and genetic information may be further protected by law. Our privacy policies will always reflect the most protective laws that apply.

Your Right to Privacy We are required by law to provide you with the Notice of Privacy Practices. This notice is included in your member packet and our member newsletter. This notice informs you of your rights about the privacy of your personal information and how we may use and share your personal information. Changes to this notice will apply to the information that we already have about you as well as any information that we may receive or create in the future. You may request a copy at any time by calling Member Services at 1‑855‑652‑8249 or by going to our website at www.aetnabetterhealth.com/virginia.


In your doctor’s office, your medical record will be labeled with your identification and stored in a safe location in the office where other people cannot see your information. If your medical information is on a computer, there is a special password needed to see that information.

Your medical record cannot be sent to anyone else without your written permission, unless required by law. When you ask your doctor’s office to transfer records, they will give you a release form to sign. It’s your doctor’s office responsibility to do this service for you. If you have a problem getting your records or having them sent to another doctor, please contact our Member Services at 1‑855‑652‑8249 (TTY/TDD: 711 or 1‑800‑828‑1120).

Our Member Services department will help you get your records within 10 working days of the record request.

We will assist you:

To provide quick transfer of records to other in or outofnetwork providers for the medical management of your health

When you change primary care providers, to assure that your medical records or copies of medical records are made available to your new primary care provider.

If you would like a copy of your medical or personal records, you may send us a written request. You may also call Member Services at 1‑855‑652‑8249 (TTY/TDD: 711 or 18008281120) and ask for a form that you or your representative can fill out and send back to us. You have a right to review your requested medical records and ask they be changed or corrected.

How to Join the Member Advisory CommitteeAetna Better Health would like you to help us improve our health plan. We invite you to join our Member Advisory Committee. On the committee, you can let us know how we can better serve you. Going to these meetings will give you and your caregiver or family Member the chance to help plan meetings and meet other Members in the community. These educational meetings are held once every three months. If you would like to attend or would like more information, please contact Aetna Better Health Member Services using one of the numbers below.


Nondiscrimination Notice

Aetna complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Aetna does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Aetna:• Provides free aids and services to people with disabilities to communicate effectively

with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats,

other formats)• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreterso Information written in other languages

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card or 1-800-385-4104. (TTY: 711)

If you believe that Aetna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our Civil Rights Coordinator at:

Address: Attn: Civil Rights Coordinator 4500 East Cotton Center BoulevardPhoenix, AZ 85040

Telephone: 1-888-234-7358 (TTY 711)Email: [email protected]

You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, and its affiliates.


Multi-language Interpreter Services

ENGLISH: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on the back of your ID card or 1-800-385-4104 (TTY: 711).

SPANISH: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en el reverso de su tarjeta de identificación o al 1-800-385-4104 (TTY: 711).

KOREAN: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드 뒷면에 있는 번호로나 1-800-385-4104 (TTY: 711) 번으로 연락해 주십시오.

VIETNAMESE: CHÚ Ý: nếu bạn nói tiếng việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Hãy gọi số có ở mặt sau thẻ id của bạn hoặc 1-800-385-4104 (TTY: 711).

CHINESE: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電您的 ID 卡背面的電話號碼或 1-800-385-4104 (TTY: 711)。

ARABIC:

TAGALOG: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tumawag sa numero na nasa likod ng iyong ID card o sa 1-800-385-4104 (TTY: 711).PERSIAN:

AMHARIC: ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ ያለ ምንም ክፍያ የቋንቋ ድጋፍ አገልግሎቶችን ማግኘት ይችላሉ። በእርስዎ አይዲ ካርድ ጀርባ ወዳለው ስልክ ቁጥር ወይም በስልክ ቁጥር 1-800-385-4104 (TTY: 711) ይደውሉ።.

URDU:

FRENCH: ATTENTION: si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le numéro indiqué au verso de votre carte d’identité ou le 1-800-385-4104 (ATS : 711).

RUSSIAN: ВНИМАНИЕ: если вы говорите на русском языке, вам могут предоставить бесплатные услуги перевода. Позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки, или по номеру 1-800-385-4104 (TTY: 711).

HINDI: ध्यान दें: ्दद आप हिदंी भयाषया बोलते िैं तो आपके ललए भयाषया सिया्तया सेवयाएं लन: शुलक उपलब्ध िैं। अपने आईडी कयाड्ड के पृष्ठ भयाग में ददए गए नमबर अथवया 1-800- 385-4104 (TTY: 711) पर कॉल करें।GERMAN: ACHTUNG: Wenn Sie deutschen sprechen, können Sie unseren kostenlosen Sprachservice nutzen. Rufen Sie die Nummer auf der Rückseite Ihrer ID-Karte oder 1-800-385-4104 (TTY: 711) an.

BENGALI: লক্ষ্য কর‍ুনঃ যদি আপদন বাংলায় কথা বললন, তাহলল দনঃ খরচায় ভাষা সহায়তা পদরলষবা উপলব্ধ আলে। আপনার পদরচয়পলরের উল্াদিলক থাকা নম্বলর অথবা 1-800- 385-4104 (TTY: 711) নম্বলর ফ�ান কর‍ুন।

IGBO (IBO): NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ nọmba dị n’azụ nke kaadị ID gị ma ọ bụ 1-800-385-4104 (TTY: 711).

YORUBA: ÀKÍYÈSÍ: Tí o bá sọ èdè Yorùbá, àwọn olùrànlọ́wọ́ ìpèsè èdè ti wá ní lẹ̀ fún ọ lọ́fẹ̀ẹ́, pe nọ́ńbà tí ó wà lẹ́yìn káàdì ìdánimọ̀ rẹ tàbí 1-800-385-4104 (TTY: 711).

VA-16-09-02

ملحوظة: إذا كنت تتحدث باللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل على الرقم الموجود خلف بطاقتك الشخصية أو عل 4104-385-800-1 )للصم والبكم: 711(.

ARABIC:

اگر به زبان فارسی صحبت می کنيد، به صورت رايگان می توانيد به خدمات کمک زبانی دسترسی داشته باشيد. با شماره درج شده در پشت کارت شناسايی يا با شماره TTY: 711( 1-800-385-4104( تماس بگيريد.

PERSIAN:

توجہ دیں: اگر آپ اردو زبان بولتے ہیں، تو زبان سے متعلق مدد کی خدمات آپ کے لئے مفت دستیابہیں ۔ اپنے شناختی کارڈ کے پیچھے موجود نمبر پر یا TTY: 711( 1-800-385-4104( پر رابطہ کریں۔

URDU:

KRU: TÛ DƐ NÂ JIE̍̍ BÒ: ɛ yemâ wlu bɛɛ̀ ̀ n̂ a po Klào Win, nee̍̍ â-a̍ win kwa cɛti y̍ɔ+ ne-la,̍ i bɛle-̍o̍ bi ma-̍o̍ mû bò ko̍ putu bò. Da ̍nɔbâ ne ̍ɛ ̂nea-o̍ n̂-a ̍ji̍ e ̍jipolê kateh̍ jɛ na ̍kpo̍h, mɔɔ̀ ̍1-800-385-4104 )TTY: 711).

1-800-385-4104

1-800-385-4104


17. Member Responsibilities

Your ResponsibilitiesAs a Member, you also have some responsibilities. These include:• Present your Aetna Better Health Membership card whenever you seek medical

care.• Provide complete and accurate information to the best of your ability on your health

and medical history.• Participate in your care team meetings, develop an understanding of your health

condition, and provide input in developing mutually agreed upon treatment goals to the best of your ability.

• Keep your appointments. If you must cancel, call as soon as you can.• Receive all of your covered services from Aetna Better Health’s network.• Obtain authorization from Aetna Better Health prior to receiving services that

require a service authorization review (see Section 14).• Call Aetna Better Health whenever you have a question regarding your Membership

or if you need assistance toll‑free at one of the numbers below.• Tell Aetna Better Health when you plan to be out of town so we can help you

arrange your services. • Use the emergency room only for real emergencies.• Call your PCP when you need medical care, even if it is after hours. • Tell Aetna Better Health when you believe there is a need to change your plan of

care. • Tell us if you have problems with any health care staff. Call Member Services at one

of the numbers below.• Call Member Services at one of the phone numbers below about any of the

following: – If you have any changes to your name, your address, or your phone number. Report these also to your case worker at your local Department of Social Services. – If you have any changes in any other health insurance coverage, such as from your employer, your spouse’s employer, or workers’ compensation. – If you have any liability claims, such as claims from an automobile accident. – If you are admitted to a nursing facility or hospital. – If you get care in an out‑of‑area or out‑of‑network hospital or emergency room. – If your caregiver or anyone responsible for you changes. – If you are part of a clinical research study.


Advance DirectivesYou have the right to say what you want to happen if you are unable to make health care decisions for yourself. There may be a time when you are unable to make health care decisions for yourself. Before that happens to you, you can:• Fill out a written form to give someone the right to make health care decisions for

you if you become unable to make decisions for yourself. • Give your doctors written instructions about how you want them to handle your

health care if you become unable to make decisions for yourself.

The legal document that you can use to give your directions is called an advance directive. An advance directive goes into effect only if you are unable to make health care decisions for yourself. Any person age 18 or over can complete an advance directive. There are different types of advance directives and different names for them. Examples are a living will, a durable power of attorney for health care, and advance care directive for health care decisions.

You do not have to use an advance directive, but you can if you want to. Here is what to do.

Where to Get the Advance Directives FormYou can get the Virginia Advance Directives form at: http://www.vdh.virginia.gov/OLC/documents/2011/pdfs/2011‑VA‑AMD‑Simple.pdf.

You can also get the form from your doctor, a lawyer, a legal services agency, or a social worker. Organizations that give people information about Medicaid, such as Hospice and Home Care may also have advance directive forms. You can also contact Member Services at 1‑855‑652‑8249; TTY/TDD 711 or 1‑800‑828‑1120 to ask for the forms.

Completing the Advance Directives FormFill it out and sign the form. The form is a legal document. You may want to consider having a lawyer help you prepare it. There may be free legal resources available to assist you.

Share the Information with People You Want to Know About ItGive copies to people who need to know about it. You should give a copy of the Living Will, Advance Care Directive, or Power of Attorney form to your doctor. You should also give a copy to the person you name as the one to make decisions for you. You may also want to give copies to close friends or family members. Be sure to keep a copy at home.

If you are going to be hospitalized and you have signed an advance directive, take a copy of it to the hospital. The hospital will ask you whether you have signed an advance directive form and whether you have it with you. If you have not signed an


advance directive form, the hospital has forms available and will ask if you want to sign one.

We Can Help You Get or Understand Advance Directives DocumentsYour Care Coordinator can help you understand or get these documents. They do not change your right to quality health care benefits. The only purpose is to let others know what you want if you can’t speak for yourself.

Remember, it is your choice to fill out an advance directive or not. You can revoke or change your advance care directive or power of attorney if your wishes about your health care decisions or authorized representative change.

Other ResourcesYou may also find information about advance directives in Virginia at: Error! Hyperlink reference not valid.

You can store your advance directive at the Virginia Department of Health Advance Healthcare Directive Registry: www.virginiaregistry.org/.

If Your Advance Directives Are Not FollowedIf you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the following organizations.

For complaints about doctors and other providers, contact the Enforcement Division at the Virginia Department of Health Professions:

CALL Virginia Department of Health Professions:Toll‑Free Phone: 1‑800‑533‑1560Local Phone: 804‑367‑4691

WRITE Virginia Department of Health ProfessionsEnforcement Division9960 Mayland Drive, Suite 300Henrico, Virginia 23233‑1463

FAX 804‑527‑4424

EMAIL [email protected] WEBSITE http://www.dhp.virginia.gov/Enforcement/complaints.htm

For complaints about nursing facilities, inpatient and outpatient hospitals, abortion facilities, home care organizations, hospice programs, dialysis facilities, clinical laboratories, and health plans (also known as managed care organizations), contact the Office of Licensure and Certification at the Virginia Department of Health:


CALL Toll‑Free Phone: 1‑800‑955‑1819Local Phone: 804‑367‑2106

WRITE Virginia Department of HealthOffice of Licensure and Certification9960 Mayland Drive, Suite 401Henrico, Virginia 23233‑1463

FAX 804‑527‑4503EMAIL OLC‑[email protected] WEBSITE http://www.vdh.state.va.us/olc/complaint/

18. Fraud, Waste, and Abuse

Committing fraud or abuse is against the law. Fraud is a dishonest act done on purpose. Examples of fraud are:• Letting someone else use your Aetna Better Health ID card(s) or• Getting prescriptions with the idea of abusing or selling drugs

Abuse is an act that does not follow good practices. Example of member abuse:• Going to the emergency room for something that is not an emergency• Provider abuse is prescribing a more expensive item than needed• Giving you treatment or services you do not need

What is Fraud, Waste, and AbuseFraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

Waste includes overutilization, underutilization, or misuse of resources. Waste typically is not an intentional act, but does result in spending that should not have occurred. As a result, waste should be reported so that improper payments can be identified and corrected

Abuse includes practices that are inconsistent with sound fiscal, business, or medical practice, and result in unnecessary cost to the Medicaid program, payment for services that are not medically necessary, or fail to meet professionally recognized health care standards.


Common types of health care fraud, waste, and abuse include: • Medical identity theft • Billing for unnecessary items or services or Billing for items or services not provided

or Billing a code for a more expensive service or procedure than was performed (known as up‑coding)

• Charging for services separately that are generally grouped together (Unbundling) or charging for Items or services not covered

• When one doctor receives a form of payment in return for referring a patient to another doctor. These payments are called “kickbacks.”

How Do I Report Fraud, Waste, or AbuseYou should report instances of fraud and abuse to Aetna Better Health of Virginia Fraud and Abuse Help Line at: • Phone: 1‑844‑317‑5825 (TTY/TDD: 1‑800‑828‑1120 or 711) • Email: [email protected].

If you would prefer to refer your fraud, waste, or abuse concerns directly to the State, you can report to the contacts listed below.

Department of Medical Assistance Services Fraud Hotline• Phone: 1‑800‑371‑0824 or 1‑866‑486‑1971 or 804‑786‑1066

Virginia Medicaid Fraud Control Unit (Office of the Attorney General)• Email: [email protected] • Fax: 804‑786‑3509• Mail: Office of the Attorney General

Medicaid Fraud Control Unit 202 North Ninth Street Richmond, VA 23219

Virginia Office of the State Inspector General Fraud, Waste, and Abuse Hotline• Phone 1‑800‑723‑1615• Fax: 804‑371‑0165• Email: [email protected]• Mail: State FWA Hotline

101 N. 14th Street The James Monroe Building 7th Floor Richmond, VA 23219


19. Other Important Resources

CCC Plus Helpline1‑844‑374‑9159cccplusva.com

Department of Medical Assistance Services (DMAS)www.dmas.virginia.gov

Virginia Division for the Aginghttp://www.vda.virginia.gov/aaalist.aspIncludes a list of area agencies on aging by location

Department of Social Serviceswww.dss.virginia.gov

Reporting Abuse, Neglect, and ExploitationAdult Protective Services (APS)24 Hour Hotline1‑888‑832‑3858

You can also find additional community resources on our website at www.aetnabetterhealth.com/virginia. Select “Health and Wellness” from the navigation menu, then choose “Community Resources.”

The Virginia Department for the Deaf and Hard of Hearing (VDDHH) The Technology Assistance Program (TAP) provides telecommunication equipment to qualified applicants whose disabilities prevent them from using a standard telephone. VDDHH outreach specialists can also provide information and referral for assistive technology devices.• 804‑662‑9502 (Voice / TTY)• 1‑800‑552‑7917 (Voice / TTY)• 804‑662‑9718 (Fax)• 1602 Rolling Hills Drive, Suite 203

Richmond, VA 23229‑5012• http://www.vddhh.org


20. Important Words and Definitions Used in this Handbook• Adverse benefit determination: Any decision to deny a service authorization

request or to approve it for an amount that is less than requested.• Appeal: A way for you to challenge an adverse benefit determination (such as

a denial or reduction of benefits) made by Aetna Better Health of Virginia if you think we made a mistake. You can ask us to change a coverage decision by filing an appeal.

• Activities of daily living: The things people do on a normal day, such as eating, using the toilet, getting dressed, bathing, or brushing the teeth.

• Balance billing: A situation when a provider (such as a doctor or hospital) bills a person more than Aetna Better Health’s cost‑sharing amount for services. We do not allow providers to “balance bill” you. Call Member Services if you get any bills that you do not understand.

• Brand name drug: A prescription drug that is made and sold by the company that originally made the drug. Brand name drugs have the same ingredients as the generic versions of the drugs. Generic drugs are made and sold by other drug companies.

• Care Coordinator: One main person from our Aetna Better Health plan who works with you and with your care providers to make sure you get the care you need.

• Care coordination: A person‑centered individualized process that assists you in gaining access to needed services. The Care Coordinator will work with you, your family Members, if appropriate, your providers and anyone else involved in your care to help you get the services and supports that you need.

• Care plan: A plan for what health and support services you will get and how you will get them.

• Care team: A care team may include doctors, nurses, counselors, or other health professionals who are there to help you get the care you need. Your care team will also help you make a care plan.

• CCC Plus Helpline: an Enrollment Broker that DMAS contracts with to perform choice counseling and enrollment activities.

• Centers for Medicare & Medicaid Services (CMS): The federal agency in charge of Medicare and Medicaid programs.

• Coinsurance: See the definition for cost sharing.• Complaint: A written or spoken statement saying that you have a problem or

concern about your covered services or care. This includes any concerns about the quality of your care, our network providers, or our network pharmacies. The formal name for “making a complaint” is “filing a grievance.”


• Copayment: See the definition for cost sharing.• Cost sharing: the costs that members may have to pay out of pocket for covered

services. This term generally includes deductibles, coinsurance, and copayments, or similar charges. Also, see the definition for patient pay.

• Coverage decision: A decision about what benefits we cover. This includes decisions about covered drugs and services or the amount we will pay for your health services.

• Covered drugs: The term we use to mean all of the prescription drugs covered by Aetna Better Health.

• Covered services: The general term we use to mean all of the health care, long‑term services and supports, supplies, prescription and over‑the‑counter drugs, equipment, and other services covered by Aetna Better Health.

• Durable medical equipment: Certain items your doctor orders for you to use at home. Examples are walkers, wheelchairs, or hospital beds.

• Emergency medical condition: An emergency means your life could be threatened or you could be hurt permanently (disabled) if you don’t get care quickly. If you are pregnant, it could mean harm to the health of you or your unborn baby.

• Emergency medical transportation: Your condition is such that you are unable to go to the hospital by any other means but by calling 911 for an ambulance.

• Emergency room care: A hospital room staffed and equipped for the treatment of people that require immediate medical care and/or services.

• Emergency services: Services provided in an emergency room by a provider trained to treat a medical or behavioral health emergency.

• Excluded services: Services that are not covered under the Medicaid benefit.• Fair hearing: See State Fair Hearing. The process where you appeal to the State on

a decision made by us that you believe is wrong.• Fee‑for‑service: The general term used to describe Medicaid services covered by

the Department of Medical Assistance Services (DMAS).• Generic drug: A prescription drug that is approved by the federal government to

use in place of a brand name drug. A generic drug has the same ingredients as a brand name drug. It is usually cheaper and works just as well as the brand name drug.

• Grievance: A complaint you make about us or one of our network providers or pharmacies. This includes a complaint about the quality of your care.

• Habilitation services and devices: Services and devices that help you keep, learn, or improve skills and functioning for daily living.


• Health insurance: Type of insurance coverage that pays for health, medical and surgical expenses incurred by you.

• Health plan: An organization made up of doctors, hospitals, pharmacies, providers of long‑term services, and other providers. It also has Care Coordinators to help you manage all your providers and services. They all work together to provide the care you need.

• Health risk assessment: A review of a patient’s medical history and current condition. It is used to figure out the patient’s health and how it might change in the future.

• Home health aide: A person who provides services that do not need the skills of a licensed nurse or therapist, such as help with personal care (like bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home health aides do not have a nursing license or provide therapy.

• Home health care: Health care services a person receives in the home including nursing care, home health aide services, and other services.

• Hospice services: A program of care and support to help people who have a terminal prognosis live comfortably. A terminal prognosis means that a person has a terminal illness and is expected to have six months or less to live. An enrollee who has a terminal prognosis has the right to elect hospice. A specially trained team of professionals and caregivers provide care for the whole person, including physical, emotional, social, and spiritual needs.

• Hospitalization: The act of placing a person in a hospital as a patient.• Hospital outpatient care: Care or treatment that does not require an overnight

stay in a hospital.• List of Covered Drugs (Drug List): A list of prescription drugs covered by Aetna

Better Health. Aetna Better Health chooses the drugs on this list with the help of doctors and pharmacists. The Drug List tells you if there are any rules you need to follow to get your drugs. The Drug List is sometimes called a “formulary.”

• Long‑term services and supports (LTSS): A variety of services and supports that help elderly individuals and individuals with disabilities meet their daily needs for assistance, improve the quality of their lives, and maintain maximum independence. Examples include assistance with bathing, dressing, toileting, eating, and other basic activities of daily life and self‑care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over a long period of time, usually in homes and communities, but also in facility‑based settings such as nursing facilities. Most of these services help you stay in your home so you don’t have to go to a nursing facility or hospital.


• Medically Necessary: This describes the needed services to prevent, diagnose, or treat your medical condition or to maintain your current health status. This includes care that keeps you from going into a hospital or nursing facility. It also means the services, supplies, or drugs meet accepted standards of medical practice or as necessary under current Virginia Medicaid coverage rules.

• Medicaid (or Medical Assistance): A program run by the federal and the state government that helps people with limited incomes and resources pay for long‑term services and supports and medical costs. It covers extra services and drugs not covered by Medicare. Most health care costs are covered if you qualify for both Medicare and Medicaid.

• Medicare: The federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end‑stage renal disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare or a managed care plan (see “Health plan”).

• Medicare‑covered services: Services covered by Medicare Part A and Part B. All Medicare health plans must cover all of the services that are covered by Medicare Part A and Part B.

• Medicare‑Medicaid enrollee: A person who qualifies for Medicare and Medicaid coverage. A Medicare‑Medicaid enrollee is also called a “dual eligible beneficiary.”

• Medicare Part A: The Medicare program that covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.

• Medicare Part B: The Medicare program that covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) that are medically necessary to treat a disease or condition. Medicare Part B also covers many preventive and screening services.

• Medicare Part C: The Medicare program that lets private health insurance companies provide Medicare benefits through a Medicare Advantage Plan.

• Medicare Part D: The Medicare prescription drug benefit program. (We call this program “Part D” for short.) Part D covers outpatient prescription drugs, vaccines, and some supplies not covered by Medicare Part A or Part B or Medicaid.

• Member Services: A department within Aetna Better Health responsible for answering your questions about your Membership, benefits, grievances, and appeals.

• Model of care: A way of providing high‑quality care. The CCC Plus model of care includes care coordination and a team of qualified providers working together with you to improve your health and quality of life.


• Network: “Provider” is the general term we use for doctors, nurses, and other people who give you services and care. The term also includes hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long‑term services and supports. They are licensed or certified by Medicaid and by the state to provide health care services. We call them “network providers” when they agree to work with the Aetna Better Health and accept our payment and not charge our Members an extra amount. While you are a Member of Aetna Better Health, you must use network providers to get covered services. Network providers are also called “plan providers.”

• Network pharmacy: A pharmacy (drug store) that has agreed to fill prescriptions for Aetna Better Health Members. We call them “network pharmacies” because they have agreed to work with Aetna Better Health. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

• Non‑participating provider: A provider or facility that is not employed, owned, or operated by Aetna Better Health and is not under contract to provide covered services to Members of Aetna Better Health.

• Nursing facility: A medical care facility that provides care for people who cannot get their care at home but who do not need to be in the hospital. Specific criteria must be met to live in a nursing facility.

• Ombudsman: An office in your state that helps you if you are having problems with Aetna Better Health or with your services. The ombudsman’s services are free.

• Out‑of‑network provider or Out‑of‑network facility: A provider or facility that is not employed, owned, or operated by Aetna Better Health and is not under contract to provide covered services to Members of Aetna Better Health.

• Participating provider: Providers, hospitals, home health agencies, clinics, and other places that provide your health care services, medical equipment, and long‑term services and supports that are contracted with Aetna Better Health. Participating providers are also “in‑network providers” or “plan providers.”

• Patient Pay: The amount you may have to pay for long‑term care services based on your income. The Department of Social Services (DSS) must calculate your patient pay amount if you live in a nursing facility or receive CCC Plus Waiver services and have an obligation to pay a portion of your care. DSS will notify you and Aetna Better Health if you have a patient pay, including the patient pay amount (if any).

• Physician services: Care provided to you by an individual licensed under state law to practice medicine, surgery, or behavioral health.


• Plan: An organization made up of doctors, hospitals, pharmacies, providers of long‑terVm services, and other providers. It also has Care Coordinators to help you manage all your providers and services. They all work together to provide the care you need.

• Prescription drug coverage: Prescription drugs or medications covered (paid) by your Aetna Better Health. Some over‑the ‑counter medications are covered.

• Prescription drugs: A drug or medication that, by law, can be obtained only by means of a physician’s prescription.

• Primary Care Physician (PCP): Your primary care physician (also referred to as your primary care provider) is the doctor who takes care of all of your health needs. They are responsible to provide, arrange, and coordinate all aspects of your health care. Often they are the first person you should contact if you need health care. Your PCP is typically a family practitioner, internist, or pediatrician. Having a PCP helps make sure the right medical care is available when you need it.

• Prosthetics and Orthotics: These are medical devices ordered by your doctor or other health care provider. Covered items include, but are not limited to, arm, back, and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function.

• Provider: A person who is authorized to provide your health care or services. Many kinds of providers participate with Aetna Better Health, including doctors, nurses, behavioral health providers, and specialists.

• Premium: A monthly payment a health plan receives to provide you with health care coverage.

• Private duty nursing services: skilled in‑home nursing services provided by a licensed RN, or by an LPN under the supervision of an RN, to waiver members who have serious medical conditions or complex health care needs.

• Referral: In most cases, you PCP must give you approval before you can use other providers in Aetna Better Health’s network. This is called a referral.

• Rehabilitation services and devices: Treatment you get to help you recover from an illness, accident, injury, or major operation.

• Service area: A geographic area where Aetna Better Health is allowed to operate. It is also generally the area where you can get routine (non‑emergency) services.

• Service authorization: Also known as preauthorization. Approval needed before you can get certain services or drugs. Some network medical services are covered only if your doctor or other network provider gets an authorization from Aetna Better Health.


• Skilled nursing care: care or treatment that can only be done by licensed nurses. Examples of skilled nursing needs include complex wound dressings, rehabilitation, tube feedings, or rapidly changing health status.

• Skilled Nursing Facility (SNF): A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.

• Specialist: A doctor who provides health care for a specific disease, disability, or part of the body.

• Urgently needed care (urgent care): Care you get for a non‑life threatening sudden illness, injury, or condition that is not an emergency but needs care right away. You can get urgently needed care from out‑of‑network providers when network providers are unavailable or you cannot get to them.

Aetna Better Health Member Services

CALL

1‑855‑652‑8249Calls to this number are free. 24 hours a day/7 days a weekMember Services also has free language interpreter services available for non‑English speakers.

TTY 1‑800‑828‑1120Calls to this number are free. 24 hours a day/7days a week

FAX 1‑866‑207‑8901

WRITE

Aetna Better Health of VirginiaAttn: Member Services9881 Mayland DriveRichmond, VA [email protected]

WEB SITE www.aetnabetterhealth.com/virginia


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